Does taking Prozac winnow away that sadness that is so dear to life, so essential some say, rendering one inauthentic? Are we to maintain the true self at all costs, foregoing treatment in an effort to avoid falsity? Could the medicated self actually be the true self? Ultimately, depression is nasty. Depression kills and any assuaging of its despair are not to be taken lightly.

Depression, whether mild, moderate, or severe is a crippling disorder. According to the World Health Organization (WHO) more that 300 million people worldwide suffer from depression, and depression is the leading global cause of disability. Generally, more women than men are affected, whites have higher rates of depression than blacks and Hispanics, and the poor are more depressed than the rich. According to the Centers for Disease Control and Prevention (CDC), depression is associated with an increased risk of suicide, lower workplace productivity, other mental disorders such as anxiety, and even smoking.

The problem of depression is widespread. “In 2015, an estimated 16.1 million adults aged 18 or older in the United States had at least one major depressive episode in the past year. This number represented 6.7% of all U.S. adults”. Looking at this in terms of happiness, according to the Pew Research Center, “Just a third (34%) of adults in this country say they’re very happy…Another half say they are pretty happy and 15% consider themselves not too happy.” For casual purposes, we can identify unhappiness as a condition of life and depression as an illness, although the two bleed into one another.

Happiness on a global scale has been measured by Helliwell and coauthors. using the World Happiness Report [1]. The United States ranks number fourteen, with Norway ranking highest in happiness, although the difference between the two is not statistically significant. It’s interesting to note that eight of the bottom ten countries, the unhappiest of all, are in Africa. Faced with civil wars, famine, drought, pestilence, and disease, it’s not hard to imagine being unhappy under such circumstances. It’s estimated that 500,000 to 1 million people died in the Ethiopian famine of 1983 to 1985. In 1988, researchers in Ethiopia found that “women in Addis Ababa in 1988…94 out of a sample of 113…were suffering from what they described as ‘oppression of the soul’…something equivalent to chronic depression” [2].

In terms of cost, according to the CDC, “the economic burden of depression, including workplace costs, direct costs and suicide-related costs, was estimated to be $210.5 billion in 2010.” Drugs like Prozac are, of course, a substantial portion of this disease cost. According to Nassir Ghaemi, “…psychiatric medicines are second only to cardiology drugs as the most profit-making class of drugs in the world…” [3].

Suicide

A touchstone of depression is suicide, the tragic consequence of a treatable disease’s ultimate finality. Heart disease and cancer consistently rank as the number one and number two contributors to mortality. And also consistently, suicide comes in tenth place, which is hard to fathom. Even more alarming, “In 2013, suicide was the second leading cause of death among persons aged 15-24 years, the second among persons aged 25-34 years, the fourth among person aged 35-54 years.” In 2016, the CDC reported that “more than 40,000 people died by suicide in 2012; more than 1 million people reported making a suicide attempt in the past year; and more than 2 million adults reported thinking about suicide in the past year.” Worldwide, “An estimated 804,000 suicide deaths occurred in 2012.” To illuminate that statistic, according to the WHO “Every 40 seconds a person dies by suicide somewhere in the world and many more attempt suicide.”

According to the WHO, suicide deaths increased from 11.5 per 100,000 people in 1970 to 11.8 per 100,000 in 1980. By 1990, four years after the introduction of Prozac, the U.S. suicide death rate actually increased to 12.4 per 100,000 people. The CDC reports that from “1999 through 2014, the age-adjusted suicide rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population, with the pace of increase greater after 2006”. For the latest year available, 2015, 44,000 people in the United States died from suicide.

It’s commonly thought that suicidal thoughts “should improve as the depression improves” but there have been claims that drugs such as Prozac actually increase suicidal thoughts [4]. One explanation is that the seriously depressed are too weak to carry out a plan of suicide and once under treatment, but not fully controlled, the energy to carry out a suicide becomes possible. It’s thus very important for depressed patients undergoing new treatment to be closely monitored and made aware of such a possibility. Part of the explanation for the rise in suicide could be explained by the introduction of a “black box warning” for drugs such as Prozac, disclosing the possibility of suicidal ideation. It was in 2004 that the Food and Drug Administration.

“Issued a public warning…about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. In 2006, an advisory committee to the FDA recommended that the agency extend the warning to include young adults up to age 25.”

As a result, as reported by NBC News, many of those taking Prozac and similar antidepressants, including children with worried parents, quit the drugs, leaving them untreated and vulnerable.

Getting diagnosed

To be “properly” diagnosed with depression, or major depressive disorder, according to the American Psychiatric Association (APA), a person must experience five or more symptoms from the list below for a continuous period of at least two weeks:

• Feelings of sadness, hopelessness, depressed mood

• Loss of interest or pleasure in activities that used to be enjoyable

• Change in weight or appetite (either increase or decrease)

• Change in activity: psychomotor agitation (being more active than usual) or psychomotor retardation (being less active than usual)

• Insomnia (difficulty sleeping) or sleeping too much

• Feeling tired or not having any energy

• Feelings of guilt or worthlessness

• Difficulties concentrating and paying attention

• Thoughts of death or suicide.

The CDC notes that “most symptoms must be present every day or nearly every day and must cause significant distress or problems in daily life functioning.”

Prozac to the rescue

Released in December of 1987 was Eli Lilly’s Prozac, a drug designed to increase the amount of serotonin in the brain. An SSRI, or selective serotonin reuptake inhibitor, Prozac blocks the reabsorption of serotonin within brain synapses once it has been released as a signaling agent. The name Prozac was created by Interbrand, a leading global branding company. The name has been key in its success, indicating qualities of “positive, professional, quick, proey, zaccy” [5]. After testing Prozac for a variety of disorders, “Finally, Eli Lilly tested it on mild depressives. Five recruits tried it; all five cheered up. By 1999, it was providing Eli Lilly with more than 25% of its $10 billion revenue” [5].

Prozac and drugs like it soared. “The share of psychiatric patients receiving prescriptions increased from a quarter of all office visits in 1975 to fully one-half by 1990” [6]. In addition, “Studies suggest that in America, depression more than doubled between 1991 and 2001” [5]. This could very well be the case of a drug seeking its diagnosis and certainly plays to the media attention given depression since the release of Prozac. However, and unfortunately, “While one in five Americans lives with a mental health condition, only about 50% of those people receive mental health services” [7].

According to the CDC, the percent of the population prescribed Prozac and other antidepressants rose three-hundred-fold from 1988 to 2012. The assumption that perhaps physicians were looking harder for depression may explain the vast increase of antidepressant prescriptions. Also, with the new openness to depression, as evidenced by the rise in popular literature associated with Prozac, people felt more comfortable admitting that they were depressed and thus more willing to seek treatment and to take medication.

Prozac was the first drug of its kind to gain a wide popular following, but there have been other drugs that have created an allegiance. Chloral hydrate first appeared in 1832 in Germany and was found wildly popular as a hypnotic. “Chloral became the first rehearsal of the ‘Prozac’ scenario seen with drugs that acquire a great public following for the relief of common psychiatric symptoms” [6]. Similar blockbuster scenarios occurred with the tranquilizer Miltown in 1955 and its successor Valium in the 1960s, 70s, and 80s.

In conjunction with the newness of depression as a more or less common disorder was a new phenomenon, depression emerging within popular literature, most notably Elizabeth Wurtzel’s Prozac Nation, which set off two decades of popular texts aimed at supporting and vilifying the enhancement qualities of SSRIs such as Prozac and bemoaning the loss of one’s identity [8-31].

Here is a list of the most visible and widespread literature:

• “Darkness Visible” by William Styron [8].

• “Prozac Nation” by Elizabeth Wurtzel [14].

• “Beyond Prozac: Brain-toxic lifestyles, natural antidotes and new generation antidepressants” by Michael Norden [15].

• “Listening to Prozac” by Peter Kramer [23]

• “Prozac Diary” by Lauren Slater [19]

• “Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives” by Joseph Glenmullen [12]

• “Better Than Well: American Medicine Meets the American Dream” by Carl Elliott [25]

• “Prozac As a Way of Life” by Carl Elliott and Tod Chambers [30]

• “Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression” by David Healy [22]

• “The Age of Melancholy” by Dan Blazer in 2005.

• “Against Depression” by Peter Kramer [31]

• “Artificial Happiness: The Dark Side of the New Happy Class” by Ronald Dworkin [21]

• “Poets on Prozac: Mental Illness, Treatment, and the Creative Process” by Richard Berlin [20]

• “Against Happiness: In Praise of Melancholy” by Eric Wilson [13]

• “Comfortably Numb: How Psychiatry is Medicating a Nation” by Charles Barber [9]

• “On Depression” by Nassir Ghaemi [3]

• “Ordinarily Well: The Case for Antidepressants” by Kramer [10].

This deluge of books and articles discussing Prozac and drugs like it is itself unprecedented.

The Rudiments of Depression

So, what is depression more fully, beyond the clinical view espoused by the APA? The writer William Styron describes depression from his gut using concrete language. Perhaps it was his memoir published in 1990 that really got the depression train moving. Styron notes “...the ferocious inwardness of the pain…”[8]. He also notes that the “...failure of alleviation is one of the most distressing factors of the disorder…” [8], which is very true in the absence of effective treatment with drugs such as Prozac or through psychological intervention or both. Even staunch anti-Prozac writer Charles Barber says this: “Truly depressed people shake physically, are unable to get out of bed, and exude a profound heaviness or lifelessness, exhibiting a sort of death in life”[9]. Psychiatrist David Kramer, perhaps the lion of Prozac use, says that depression is “a progressive, probably lifelong disorder” [10]. Kramer even advocates that once treated for depression that the treatment should be lifelong as well. From Goethe’s The Sorrows of Young Werther, we have this prescient text: “The leaven which animated my existence is gone: the charm which cheered me in the gloom of night, and aroused me from my morning slumbers, is forever fled” [11]. Was it better for Young Werther to suffer than be helped?

Many think that it is necessary to distinguish sadness from depression, thinking that sadness is an apt human characteristic that is dangerous to take away. According to Joseph Glenmullen, “Genuine sadness is quite different from depression. Sadness is a clarifying, relieving emotion that helps one move on after losses” [12]. Eric Wilson thinks of sadness and depression as a continuum: “Of course there is a fine line between what I’m calling melancholia and what society calls depression. In my mind, what separates the two is degree of activity” [13].

Depression is serious, think about suicide, perhaps sadness gone askew. So, does sadness alone induce suicidal ideation? Perhaps not, but if the sadness has bled into the realm of extreme sadness, then we can label that as depression, which is deserving of treatment. However, sadness should be viewed as a symptom of depression versus being within its own sterile category. When Wurtzel says “So as far as I’m concerned, the last shower I took is the last shower I will ever take” then we all need to be worried, sad or not. Sylvia Plath said a similar thing about washing her hair, the futility, that she would only have to repeat the motion, and what is the good of that, a despair of life in total [14].

Why do some people get depressed and others do not? Barber’s answer is that “Psychiatric disorders are almost certainly the dialectical product of an infinitely complex dialogue between genes and the environment” [9]. Norden expounds on the environment, finding fault with the stress of modern society: “These cumulative stresses of modern life have set off an avalanche of depression, anxiety, and insomnia”[15]. Considering life’s rough patches, Kramer adds that “People don’t have to be made vulnerable by trauma: they can be born vulnerable” [10]. And ultimately, the crux of an argument for antidepressants is that “depression...ruins lives” [14].

Prozac Nation

Let us turn to that famous book, turned into an equally infamous movie, Prozac Nation by Elizabeth Wurtzel who says that “the deeply depressed are just the walking, waking dead” [14]. She gives us vivid accounts of what it is like to be seriously depressed. For example “I walked away from Ruby lost in vertigo. The Yard seemed like a phantom. I moved through it in the plastic bubble that separated my fogworld from everything around me” [14]. She gives us the effect of depression on setting, giving dead life to inanimate objects with flair.

In addition to the lifelessness of person and place and, Wurtzel recounts what is most oppressive about depression, the debilitation of the routine. “While I was still in my old room at home, I discovered that the hardest part of each day, as is the case with most depressives, was simply getting out of bed in the morning. If I could do that much I had a fighting chance” [14]. Who wouldn’t want to take a magic pill to try and soften the edges of such a reality?

Once prescribed Prozac, Wurtzel finds that she has found her legs, has found her lot in life, as if her disease were some great egg that needed cracking. “Enter Prozac, and suddenly I have a diagnosis” [14]. And this is where the suffering can come to not an end but at least to some sort of resolution. Spending one’s day like the “walking wounded” and “constantly embroiled in thoughts of suicide” is a quick way to spoil the human experience [14]. Interestingly, though, Wurtzel embraces her diagnosis, coming to know her depression more intimately as if it were an old friend who needed a push and a hug. “I had fallen in love with my depression...I loved it because I thought it was all I had” [14].

And so, what happened to Wurtzel, once she began her regimen of Prozac? A small miracle. She says, “And then something just kind of changed in me. Over the next few days, I became all right, safe in my own skin. It happened just like that” [14]. The miracle cure, a waning of the dead thoughts, a realization that one’s love affair with depression was actually a dance with death. Once released from the claws of depression comes insight. Are we afraid of such a transformation? But Wurtzel is pragmatic, acknowledging that Prozac is “about the mainstreaming of mental illness in general and depression in particular” [14]. Prozac had made it possible to not only talk about depression but to embrace it.

So, what does Wurtzel think about the idea that the brain’s unsalted soup perhaps is the real culprit, that boosting one’s serotonin levels is akin to a magic cure? She rightly notes that “a strong, hardy, deepseated depression will outsmart any chemical” but also that “...after an accumulation of life events made my head such an ugly thing to be stuck in, my brain’s chemicals started to agree” [14]. Increased serotonin levels in the brain ergo relief from a debilitating illness. Does it matter if the drug manufacturers are having a field day? “After all, what is depression if it isn’t the most striking, poignant, psychic challenge to the American Dream” [14]?

Wurtzel has certainly had her detractors. It seems that overcoming one’s life struggle can generate wariness and skepticism among those without the experience. Found among a collection of review snippets on Amazon.com: “Wurtzel is a very entertaining nut case…” says novelist Jeffrey Euginedes. In an issue of Variety, Todd McCarthy goes a step further in his review of the book’s film: “The self-centered brat at the center of Prozac Nation spends most of her time making life miserable for everyone around her…” So, what to make of such statements?

Is describing one’s suffering on such a mundane disease as depression a crime? Is this a kind of navel gazing that uses “selfpitying passages” to glorify one’s rank among the suffering [16]. Is it less to be debilitated by depression than say a brain tumor? One would think so based on such comments. However, a review in the Library Journal sheds more sympathetic tears: “Graphically written, this book expresses the pain and anger of Wurtzel’s unremitting protest against her disability” [17]. And perhaps we can find balance in Michiko Kakutani’s review in the New York Times.

“Such self-pitying passages make the reader want to shake the author, and remind her that there are far worse fates than growing up during the 70’s in New York and going to Harvard. But Ms. Wurtzel herself is hyperaware of the narcissistic nature of her problems, and her willingness to expose herself—narcissism and all—ultimately wins the reader over. By the end of “Prozac Nation,” one is less apt to remember Ms. Wurtzel’s self-important whining than her forthrightness, her humor and her ability to write sparkling, luminescent prose.” [16].

It seems that Holly Ryan is right when she says, “mental illness, specifically depression, has become so completely ubiquitous it seems fair game for satire”, which is unfortunate [18].

Prozac Diary

Eleven years following the introduction of Prozac into the food chain in 1987, Penguin published Lauren Slater’s Prozac Diary. She first started Prozac in 1988, taking it for the next ten years. Unlike Prozac Nation, in Prozac Diary Slater spends more words getting at what Prozac does, how it makes you feel, how it changes the way you see the world. There is less talk of illness and more of what seems like a cure. Slater does very well at entangling the reader in her depression, at showing us the dead ends of daily battle, at giving us the profound relief she felt with Prozac.

Slater was very young when she first encountered a sadness that bled into genuine depression. She says, “I think, yes, I was six or seven when I first felt it, the dwindling that is depression” [19]. Compare that to how she felt on Prozac in her twenties: “This was what was different. It was as though I’d been visited by a blind piano tuner who had crept into my apartment at night, who had tweaked the ivory bones of my body, the taut strings in my skull, and now, when I pressed on myself, the same notes but with a mellower, fuller sound sprang out.”[19].

Slater, though, sees through her bliss and does express misgivings regarding her creativity: “But life’s become too good. Prozac’s a drug you should take before you go on vacation, like to the Caribbean. They should sell this stuff in the CVS, along with Coppertone and beach thongs. I feel so damned relaxed. I can’t really get anything creative done in this state” [19]. This mild damning of creativity is the subject of another paper, but the writers in Poets on Prozac would disagree with Slater, saying that Prozac and drugs like it make it possible to work, make it possible to be creative [20].

The Question of Authenticity

Prozac has not only engendered glowing self-reports of efficacy and recovery, but also has reaped unprecedented scorn. Critics have biting words about the dangers of Prozac, specifically in regard to its ability to change one’s character, to alter one’s being, as if that were a bad thing. It seems that one’s authenticity is precious, even though a crippling disorder could be pushed to the side with treatment.

The very title of Artificial Happiness: The Dark Side of the New Happy Class by Ronald Dworkin names the assumed state of those taking antidepressants and promises to entertain with the “dark side” of this ill-begotten giddiness. According to Dworkin, “Artificial Happiness robs people...lifting them only halfway out of misery while preventing them from making the changes they need to make to enjoy real happiness” [21]. To be lifted out of misery, to someone who is merely depressed, though, is a very good thing. Right? There are certainly no changes coming while one is sniffing the dregs of one’s soul laid bare to Churchill’s black dog of depression.

This artificial happiness, “anchored in neurotransmitters and drugs,” Dworkin equates as the pharmacogenic control of “one’s mind, body, and spirit” [21], and physicians have roped one’s trinity simply with little pills. What does the patient have to say here? After all, it is their mind, body, and spirit. Eric Wilson claims, “My sense is that most of us have been duped by the American craze for happiness” [13], but what better to crave than happiness?

Whereas Elizabeth Wurtzel in Prozac Nation embraces her diagnosis and treatment, relishes in the vanquishing of her melancholy, Dworkin bemoans the happification of antidepressants, specifically the SSRIs such as Prozac. He thinks that “Doctors have taken on the responsibility of curing unhappiness... not depression... through artificial means” [21]. Dworkin says that people often need “a mass of unhappiness to push them out of a bad life situation” and that swallowing pills could delay a natural process of extricating oneself from a web of depression [21].

Dworkin delves deeper than mere sadness, probing historical processes, developing a timeline that explores how one’s depression and social ills have been handed down since the 1920s to a succession of medical industries. He traces the transfer of social troubles to social workers in the 1920s, emotional troubles to psychiatrists in the 1930s, ethical dilemmas to bioethicists in the early 1960s, and spiritual duties to community groups in the 1960s. This culmination of transferred duties extended itself to physicians in general in the late 1960s, via a craze for exercise as therapy. These physicians then began to co-opt the treatment of depression, filching it from the hands of psychodynamism as given to us by Freud and others. “The medical profession now controls all three dimensions of life—the body, the mind, and the spirit—and clergymen have lost their relevance” [21]. And this is not a good thing according to Dworkin, seeming that doctors are worse than check forgers.

Dworkin sees this loss of self as unfortunate for the depressed, but gives doctors some license for their behavior, the presumed overprescribing of antidepressants, saying that “To the extent that they do mismanage patients, they do so unawares” rendering a class of patients he labels as “stupefied” [21]. Having attacked depression as an “engineering problem,” Dworkin lapses hysterical, noting that “Through sheer numbers these people [doctors] pose a greater threat to the social fabric than murderers, prostitutes, and thieves” [21].

Perhaps less cantankerous than Dworkin, David Healy, in Let Them Eat Prozac, asserts that “depression was all but unrecognized before the antidepressants…” [22]. This is a chicken and egg scenario, devaluing the lives of those who have always suffered something more than mere sadness. Did people not commit suicide before the introduction of Prozac in 1987? One thing that Healy does for us is to trace the rise of antidepressants beginning with the introduction of the tricyclics and monoamine oxidase inhibitors (MAOIs) in 1957. As early as the 1960s, low serotonin levels were presented as a precursor to depression, possibly being benefited by the early drugs but none more so than by the SSRIs to come. The first SSRI, zimelidine, was patented in 1972.

Let us return, though, to the dilemma of depression itself. How does depression make one feel? How desperate can one become to be relieved of the anguish? William Styron makes it clear in his memoir Darkness Visible that depression is insufferable. [A] sense of selfhatred…” he calls it. “[A] general feeling of worthlessness…dark joylessness…a failure of self-esteem…” [8]. Lying in bed with only thoughts of suicide, only thoughts of sheer despair, only a wicked darkness enveloping the soul, one would do most anything to escape. Styron also said of his madness that a “failure of alleviation is one of the most distressing factors of the disorder…” [8]. And it is this “ferocious inwardness of the pain” that propels one to grasp at straws whether it be suicide or Prozac [8].

Elizabeth Wurtzel of Prozac Nation reminds us that “clinical depression...ruins lives…” [14]. Even the naysayer Charles Barber, the author of Comfortably Numb: How Psychiatry Is Medicating a Nation says that “Many depressed people really, really want to die, and thinking about dying, or planning their death, takes up a great deal of time” [9].

Better Than Well

Balancing this attack on Prozac and wellness stands a stalwart and highly reasonable researcher, psychiatrist Peter Kramer, the author of the classic Listening to Prozac, as well as Against Depression, and Ordinarily Well, which is a look back and defense of a decade of criticism leveled against Listening to Prozac. Kramer famously coined the term “cosmetic psychopharmacology,” which has been taken by many as antidepressants being similar to a facelift. Kramer also coined the phrase “better than well” to describe some of his patients on Prozac and other antidepressants [23]. Is it okay to be better than well? Suppose you break your leg, receive a cast and heal, and then find you are a faster runner than before? Is there anything wrong with that? It seems that many, such as Joseph Glenmullen and Barber, are opposed to this “better than well” based on the assumption that it’s not natural or that it bestows an unfair advantage. Who doesn’t want to be “better than well,” if indeed that is possible? Will we become like Goethe’s Young Werther in one of his ecstasies: “A wonderful serenity has taken possession of my entire soul, like these sweet mornings of spring which I enjoy with my whole heart” [11]. Sounds pretty good….. But, to be fair, many are afraid of altering their psyche through medications, fearing they will not be themselves. “Some people…fear that psychoactive medications will change them…” [15]. Norden notes, though, that “my patients who take Prozac…have never complained of any loss of identity” [15]. Still, the naysayers put loss of identity forward as inauthentic and worthy of shunning. Perhaps, like Young Werther, we fear our own gratification: “I treat my poor heart like a sick child, and gratify its every fancy” [11]. But, what is one to do in the face of a disease that cripples? One seeks relief from the pain.

But still we worry. “It’s all so neat and tidy,” says Anna Moore. “There’s something in you that is off balance and one little pill can right the wrong” [5]. In his article “The Silence of Prozac,” K. Sharpe says, “Back then [1980s], I deeply resented ‘having’ to take the drugs, largely out of fear that they might change things about myself that I valued” [24]. But what about the things with little value, such as the wrenching of one’s soul? The inability to get out of bed, missing days of productive life?

Even Glenmullen, the author of Prozac Backlash, points us toward the known benefits of antidepressants. “Certainly antidepressants can have an important place in a balanced, comprehensive psychiatric treatment. For patients with moderate to severe symptoms, judicious use of medication can be invaluable, even life-saving” [12]. But, still we worry. Even Kramer says, “How much more uneasy will we be if doctors can reshape patient’s social behavior in detail, through chemicals” [10]? He continues, noting that “We are justly suspicious of tonics for the normal brain” [10]. In a nod toward the naysayers, Kramer is honest: “Mood brighteners might decrease true autonomy by distancing man from an aspect of his humanity—his legitimate despair…” [10].

But is this reaching normalcy an act of contrition? Do we all not desire to live a life free of those things that make us ill? Kramer notes that there are plenty of respected precedents for tackling what might be considered normal. He says, “The treatment of undesired nonpathologic conditions is common in medicine, such as estrogen to combat the normal effects of menopause” [10]. It is the idea of enhancement that is problematic. Menopause is a normal condition of life for older women, but is treating it an act of enhancement? Speaking of his father, Carl Elliott notes that “Strictly speaking, ‘enhancement’ constituted a significant part of what my father, a small-town southern family doctor, has been doing in his office from the time he set up shop in the late 1950s: immunizing children, freezing warts, removing moles and cysts.” [25].

Are we to deprive children of immunizations simply because their lives are being enhanced?

James Edwards asks us about simple issues such as straighter teeth or clearer skin, which many seek. “How can we, who have (some) of these advantages—advantages in the games we indeed play—moralize carelessly about the others who want them” [26]? David DeGrazia points out a genuine issue, one that is of humanitarian value. He says that “One concern is that Prozac, and other pharmaceuticals that could be used for enhancement purposes, are not available to all who might want and stand to benefit from them” [27]. Is this not an argument for applying antidepressive technology to a wider audience? Worldwide, depression is the number one cause of disability. Should we not be madly chasing down solutions, including humanitarian interventions, as we do with cancer and cardiovascular disease? As Laurence Kirmayer says, “There is a global monoculture of happiness in which we are all enjoined to work to achieve the good life…” And that is a good thing [28].

But, the naysayers would differentiate between enhancement and authenticity. Elliot says, “The question is not just where there is any moral cost to the quest to become better, but whether there is any moral cost to the quest to become different” [25]. He wants the individual to look inside for authenticity versus taking medication. He even goes so far as to say that “The ideal of authenticity says that if you are not living a life as yourself you have missed out on what life has to offer” [25]. But what if you are depressed and kill yourself? Is that authentic? Would it not have been better to seek treatment and live a full life in the shadow of a drug such as Prozac?

Wilson compares Prozac to “the two-beer buzz of canned bliss” [13]. That is a bit reductionist, considering that wellness, a feeling of contentment with life, is something we all strive for. We all want straighter teeth. We all want to look forward to the next day. Is it the idea that as part of a competitive society, those who take Prozac are somehow cheating and gaining an unfair advantage? Kramer asks, how might a drug “that alters personality…be used in a competitive society” [10]? That is a good question, but does competition not inherently imply a struggle to be the best? Someone who is depressed, who takes Prozac, may indeed acquire that “two-beer buzz” but he or she can do the same with beer. Should we discourage beer for fear that others may feel better than we do? How does a beer buzz foster inauthenticity? Does it matter that almost 85 percent of Americans already claim to be happy? [13]. Should we not root for the 15 percent who are not happy? Are they dangerous, a threat to our own happiness?

Sadness is a recurring theme among the critics of Prozac, who see in sadness a glorification of the human condition. Wilson says “…this quest for happiness at the expense of sadness, this obsession with joy without tumult, is dangerous, a deeply troubling loss of the real, of that interplay, rich and terrific, between antagonisms” [13]. But, sadness does not simply cease to exist because one takes Prozac. The uplifting effect is not primal and not all-encompassing. Life, sometimes a very hard life, goes on regardless of drugs taken, and it’s very common for someone on an antidepressant to feel sad and even very depressed on a rougher day.

Prozac does not cure depression, but merely assuages its ragged corners making life bearable. But still, “Enduring the sad existence is participating in life’s vital rhythms” [13]. I would say that enduring a sad existence is not noble and that “life’s vital rhythms” remain the same whether on or off of Prozac. But Wilson hammers away: “Sadness reconciles us to realities. It throws us into the flow of life” [13]. If that is the case, then those among us who suffer from serious depression are riding class-six rapids and holding on for dear life. There is nothing wrong with a life preserver, whether the ship is sinking or not. Wilson continues, though, with this bit of philosophical whimsy: “Feeling totally alone, I experience union with all of the living. Suffering inevitable anxiety, I undergo a vital shock. I get it: to be alive is to realize the universe’s grand polarity” [13]. Sounds romantic. But feeling totally alone without hope in the midst of a depressive episode is a terrible place to be, especially if self-harm rears its ugly head.

Wilson backs up his claims of sadness as life’s spice with a quote from Moby Dick: “So, therefore, that mortal man who hath more of joy than sorrow in him, that mortal man cannot be true—not true, or undeveloped” [13]. Ahab was one man, and not a very happy man at that, being obsessed with the white whale. One can justify one’s sad existence in any number of ways, including stigmatizing those who are not like us. But, again, those treated with Prozac do not necessarily have more joy than sorrow. The multifarious genetic and environmental components of depression create a substrate, a basic level of being that is capable of being lifted but not banished. Often the term crutch is used for Prozac, but when we think of a man with a broken leg, the crutch makes perfect sense.

But is it the Prozac alone that is contributing to this supposed robbing of sadness, this dent to authenticity? Kramer says, “It is not only medicine that maintains well-being. Once we function competently, the world may pitch in” [10]. That is very true. Putting one’s self on track brings us back to the world of the living. Spouses, children, and co-workers will take note of the change and “pitch in” as Kramer says. Why remain in a depressed and unproductive state when so many around us are counting on us? Is this pitching in of others then a blow to authenticity? No, it is called compassion. Some may call it self-interest. But, whatever it is called, the more help and support one receives while enduring a debilitating illness the better. Kramer even notes that “For those who begin free of depression, antidepressants prove protective” [10]. This notion really raises the hackles of the naysayers and hints at the strong notion of being “unfair.” We want to prevent cancer, so why not depression?

Erik Parens, in a critique of Kramer’s views, says that “Kramer goes to great pains to suggest that we—and he—need not be anxious about what Prozac will teach us regarding the authenticity of persons in general” [29]. As a clinical psychiatrist, we would expect that Kramer has the experience and knowledge to make such a claim. He sees the proof in his patients on a daily basis. Discussing a patient of Kramer’s profiled in Listening to Prozac, Parens notes that “Tess learned the authentic contours of her ‘authentic self’ from the drug” . What is wrong with that? Has Tess obtained an unfair advantage by learning her true self? Rid of the chains of depression, has she evolved into some kind of super-human we must fear? Perhaps we can go as far as Elliott and Chambers to say that she has allowed herself to be boxed, but thus enabled to be treated [30]. If one has cancer, one is a victim of cancer.

It seems that if one has depression then one is simply now in a hole and relegated to stay there. Edwards notes that “The Tess that she had been on Prozac now seemed to her the true Tess” [26]. What is to fear of the true medicated self?

Parens whittles away at Kramer’s cosmetic psychopharmacology further. He says that “…the more we use Prozac to build up our resistance to slights, the more we can expect such slights to proliferate” [29]. Is that logical? Will the world change because of those who claim treatment for sadness or depression? Parens indeed sees this as “morally problematic,” but is it morally problematic to discover a case of high blood pressure and refuse to treat it? What to make of Parens maxim that “Though one can find the self, one cannot actively change it…” [29]. Is the world not riddled with those who have overcome or perhaps degenerated into a different self? But he then says, “I believe such selftransformation can be quite admirable” [29]. One can change the basic self, if desired, but Prozac does not guarantee that as an outcome. Prozac merely treats the symptoms of depression, based on the theory that depressives suffer from a lack of certain neurotransmitters in the brain. It’s not a matter of creating a Frankenstein, but a matter of seeking a better self and not necessarily a new one.

One final quote from Parens: “Cosmetic psychopharmacology can encourage social quietism” [29]. How does one prove this? Perhaps taking Prozac creates socially addled individuals incapable of processing information as “normal” people do? Is it not simply the desire to be “normal” that is the goal? If that is the case then alreadynormal people should be subject to the same rules of social quietism.

Kramer, who has generated much of the criticism concerning Prozac, says that “my impression is that the concern over Prozac… turns almost entirely on an aesthetic valuation of melancholy” [31]. This is true. There seems to be a special place in the heart for sadness and the benefits it brings. One values the alcoholic writer who spends half of her time lying drunk in the gutter. Her writing is more real, more urgent. Would we value less the writings of Jack London, Sylvia Plath, or Virginia Woolf had they not killed themselves? Is the drowning of poet Paul Celan a cause for celebration of authenticity and trueness to self?

The True Self

Kramer has an interesting supposition here: “On a quest for authenticity, we must be open to discoveries of this sort—that what seemed to be carefully developed self was arbitrary, biologically based idiosyncrasy” [31]. Genetics do play a role in depression as does environment, just like most diseases that kill us. One’s self develops as one ages, for better or for worse. Is this change in self a claim for disingenuity? “Is there a principled basis for linking melancholy to authenticity” [31]? That there is seems to be the staple of the naysayers’ rhetoric, but there is little proof to support it. It just seems natural to assume that a drug alters one’s self, whether for the better or the worse. But we need proof. And then we need to ask ourselves if it matters. Is an improved or different self-better than living with depression clutching at a throat?

Some glorify the self as a natural condition untouched by pharmaceuticals. James Edwards says that “…when it comes to changing one’s life (1) the natural way is better than the artificial, and (2) the hard way is better than the easy” [26]. Is it not difficult to admit that one suffers from a stigmatizing disease and seek help for it? Despite the surge in antidepressant prescriptions since the release of Prozac, suicide rates have not gone down. In 2015, suicide was the second leading cause of death among those aged 15 to 34. That is astounding. That is 12,438 lives that could have possibly been saved had the “true self” been sacrificed to something “enhanced.” And these are only the cases where suicide can be clearly proven. If Prozac can save a life, why all the attention to the concern over “true self.”

In spite of the damage caused by depression, there remains the old adage of being obligated to pull one’s self up by the bootstraps and muddle along as best one can. Says Edwards: “To be well is to exercise a particular sort of self-generated and well-ordered self-determination” [26]. That’s well and good, but what resources do we have to facilitate that and why is it suspect to use them? We live in an often-cruel world. We, the depressives, need a little help here. Elliot says that “At least part of the nagging worry about Prozac and its ilk is that for all the good they do, the ills that they treat are part and parcel of the lonely, forgetful, and often unbearably sad place where we live” [32]. Yes, it is an unbearably sad place that we live, but hope exists.

Consider the great famine in Ethiopia of 1983–85. Estimates for the dead range between a half-million and one million souls killed by starvation and the diseases that accompany it. Sad indeed. And then we have the office worker in suburban America who no longer has the breath to leave his bed. Should we feel sorry for him? Should we just give him a slap on the back and say, “Giddyup?” Scholars, as Elliott says, may think that “Prozac treats the self rather than proper diseases” but what is wrong with that? However, there is no category of disease called “self” in the Diagnostic and Statistical Manual, the Bible of psychiatric diagnosis, but there is quite a lengthy entry on depression, its symptoms and suggested treatment [32]. If one wants science to uphold this idea of self being a disease that can be treated, then we need research that supports that. If it takes the self as disease to help others, then let’s make “true self” a disease.

Elliott asks, “When a person says, as did one man on Prozac, ‘I don’t have to look into the abyss anymore,’ is he necessarily better off” [32]? Of course he is. It’s not a matter of denying the abyss, but of being able to peek in and then look away versus falling in. We live in stymied world. “Thus it is not happiness we seek, exactly, but the relief from the complexities of being” [33]. Ian Hacking quoting Richard Kluft: “Part of the socially prescribed role of being ill is working to recover and leave your illness behind” [34]. The abyss exists, more so for some than others, but it exists and is capable of sucking us down to oblivion.

There is that critique that Prozac and drugs like it are created and marketed to generate illness. “Psychiatrist David Healy and others call this ‘disease mongering’: instead of creating drugs to treat diseases, we create diseases for which we can use our drugs” [3]. Is it true that “every society gets the doctors it deserves, and our doctors are merely giving us what we demand” [32]? We have cancer and we demand drugs to cure it, to treat it, to alleviate suffering, and to prolong life. Arriving at the hospital in the throes of a heart attack, we expect the works. Why not the same with depression, the number one cause of disability worldwide?

Elliott makes authenticity a precursor to the idea of alienation, which he views as a good thing. This makes some say that “a person should be alienated—that given his or her circumstances, alienation is the proper response” [32]. However, Prozac will not take away that ability to feel alienated. By admitting to the disease, one experiences categorization and resultant alienation from those not affected. Being medicated is a form of alienation, although a welcome one. We all struggle to make sense of things, to understand our insignificance and Prozac enables that sensibility.

Turning alienation toward psychic well-being, Elliott says this:

“Here is the key to the problem psychiatry has with a notion like alienation. The measure of psychiatric success is internal psychic wellbeing… Whereas what I want to suggest is that maybe psychic wellbeing is not everything” [32]. Of course, nothing is everything. But minimizing alienation and improving one’s psychic well-being is a task that we all face. What if the measure of psychic well-being is simply staying alive to live a meaningful life? The depressed face this every day and deserve agents such as Prozac, even if it means becoming “better than well,” much to the chagrin of Elliott and others.

Here is an interesting take on the issue of alienation and despair. “A life without despair would be a life without hope, for hope cannot exist except as an antidote to despair” [3]. Ghaemi rightly examines the low points of life that enrich the high points. Locked away in a Birmingham jail, Martin Luther King Jr. rallied and wrote an impassioned plea and classic argument for an end to segregation. His turmoil he turned to his advantage. But, in the grip of true depression, and not just mere sadness or perhaps rage, the vitality to rise to the occasion, which may simply be getting out bed, or writing a letter from jail, does not exist.

This brings us the wider issues surrounding alienation and despair. Says Hacking, “Love, passion, envy, tedium, regret, and quiet contentment are the stuff of the soul” [34]. Of course they are. Life is a smorgasbord of ups and downs. The plane is late and we despair, but have time to read a good book. We find ourselves in a rainstorm without an umbrella and we take joy in splashing through the puddles. These are part of the life well lived, but free of crippling depression, which makes the late plane and the rain unbearable. How much better to be in a state of mind that is receptive to the simple mistakes of planes and clouds? Whether it’s a two-beer buzz or Prozac, what does it matter?

Ghaemi, in his measured tone, asserts that “A little depression— not too much—makes you more realistic. No depression—none at all, being fully mentally healthy—makes you less realistic” [3]. Prozac may on occasion make you feel “better than well,” but Prozac is not a cure for depression. Life’s tribulations and the underlying disease go on. For the depressed and medicated, there will always remain that “little depression” and even bouts of serious depression that fight against all treatment given underlying genetic factors and environmental stressors. Prozac does not cure depression. There is no cure for depression, but thankfully researchers are trying to get beyond this controversial notion of “better than well,” which is transitory at best. In our toolbox, we have drugs, cognitive behavioral therapy, counseling, psychotherapy, and even new experimental treatments such as the use of isoflurane anesthesia, which has shown great promise, equaling that of electroconvulsive therapy for the most serious of depression cases. It may be that “We experience pain so that we may live; without pain, we die” but far too often it is that pain that ultimately leads to despair and possibly death by suicide or self-neglect [3].

Turning to the idea of sincerity as the measure of one’s authenticity, whereby drugs such as Prozac, according to Elliott, narrow “ordinary emotional range” [32]. Lionel Trilling quotes Polonius from Shakespeare’s Hamlet:

“This above all: to thine own self be true And doth it follow, as the night the day, Thou canst not then be false to any man.”

The naysayers would have us believe that being false, taking Prozac, renders one inauthentic, insincere. In the cunning sense of falsity this may be true, but achieving well-being in the face of a debilitating disease is hardly cause to be labeled as false. Trilling helps to define this sincerity: “It derived from the Latin word sincerus and first meant exactly what the Latin words means in its literal sense—clean, or sound, or pure…One spoke of sincere wine” [35]. How wonderful to be as sincere as a great wine, to be “clean, sound or pure.” But, it is the disease of depression that inhibits just that. Drugs such as Prozac allow the wine to breathe and flower. Disease makes for bad wine.

Trilling, to emphasize his point, quotes a passage from “The Scarlet Letter”: “Be true! Be True! Be true! Show freely to the world, if not your worst, yet some trait by which the worst may be inferred.” Again, that message of authenticity that comes only from deep within the troubled soul. If anything, depressives must be the truest of us all, whether medicated or not. Depression does not mince words and the worst may be inferred as suicide or a life hanging in the balance between utter despair and a groping for relief, whether it be pills or talk therapy. Goethe’s Young Werther has this to say: “Human nature,” I continued, “has its limits. It is able to endure a certain degree of joy, sorrow, and pain, but becomes annihilated as soon as this measure is exceeded” [11].

Trilling explains why he holds this need to be true to be one’s self. “Society requires of us that we present ourselves as being sincere, and the most efficacious way of satisfying this demand is to see to it that we really are sincere, that we are what we want our community to know we are” [35].

I think the key here is “to know who we are.” To know and accept that one is depressed and in need of treatment is the first step toward this liberation. To take a drug such as Prozac and realize its benefits is a step toward revealing one’s true potential, one’s “true self.” Without treatment, depression renders the individual helpless to meet society’s demands “that we really are sincere.”

In the time that it has taken you to read this essay at least thirty sincere people worldwide have taken their lives. Although the rhetoric may seem cliché, that’s one lethal act of authenticity every forty seconds.