The Personality Pill

By Anastasia Toufexis

Susan Smith has everything going for her. A self-described workaholic, she runs a Cambridge, Massachusetts, real estate consulting company with her husband Charles and still finds time to cuddle and nurture their two young kids, David, 7, and Stacey, 6. What few people know is that Susan, 44, needs a little chemical help to be a supermom: she has been taking the antidepressant Prozac for five years.

Smith never had manic depression or any other severe form of mental illness. But before Prozac, she suffered from sharp mood swings, usually coinciding with her menstrual periods. "I would become highly emotional and sometimes very angry, and I really wasn't sure why I was angry," she recalls. Charles will never forget the time she threw her wedding band at him during a spat. Now, says Susan, "the lows aren't as low as they were. I'm more comfortable with myself." And she has no qualms about her long-term relationship with a psychoactive pill: "If there's a drug that makes you feel better, you use it."

Millions agree, making Prozac the hottest psychiatric drug in history. Since its introduction five years ago, 5 million Americans -- and 10 million people worldwide -- have used it. The drug is much more than a fad: it is a medical breakthrough that has brought unprecedented relief to many patients with severe depressions, phobias, obsessions and compulsions. But it is also increasingly used by people with milder problems, and its immense popularity is raising some unsettling questions. When should Prozac be prescribed? How does a doctor draw the line between illness and normal behavior? If you feel better after taking Prozac, were you ill before? When does drug therapy become drug abuse? Will Prozac become the medically approved feel-good drug, a cocaine substitute without the dangerous highs and lows?

At medical meetings or dinner parties, the talk turns more and more often to Prozac, and what frequently sets off the discussion is a provocative book about the drug -- Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self by Dr. Peter Kramer of Brown University. Having quickly become a must-read, the book has perched near the top of the best-seller lists for three months.

The author, who uses Prozac in his private practice, is both impressed by the drug and uneasy about what its widespread use may portend for human society. In case after case, he contends, Prozac does more than treat disease; it has the power to transform personality, instill self-confidence and enhance a person's performance at work and play. One of the patients profiled in the book, an architect named Sam, claims that the drug made him "better than well." His depression lifted, and he became more poised and thoughtful, with keener concentration and a more reliable memory than ever before. Prozac, writes Kramer, seems "to give social confidence to the habitually timid, to make the sensitive brash, to lend the introvert the social skills of a salesman."

The psychiatrist maintains that the power of Prozac challenges basic assumptions about the origins and uniqueness of individual personalities. They may be less the result of experiences and more a matter of brain chemistry. If temperament lies in a tablet, is there an essential, immutable Self? Ultimately, Kramer muses, society could enter a new era of "cosmetic psychopharmacology," in which changing personality traits may be as simple as shampooing in a new hair color. "Since you only live once, why not do it as a blond?" he asks, and "why not as a peppy blond?" Already, pharmaceutical houses are churning out a whole new class of similar drugs, including Paxil and Zoloft, that mimic the effects of Prozac.

When Eli Lilly unveiled the drug in the U.S. in 1988, it didn't take long for word to spread that Prozac was special. Within two years, TV and magazines touted it as a wonder drug, and doctors could hardly write prescriptions fast enough. Soon after, a backlash set in, as reports surfaced that in very rare cases people on Prozac grew violent or intent on suicide. But the Prozac critics haven't been able to prove that the problems are caused by the drug rather than the patients' mental illness. Though the adverse publicity may have scared off some patients and doctors for a time, sales are now as strong as ever. In the U.S. an estimated 900,000 to 950,000 prescriptions are filled each month.

So what makes Prozac any different from all the other popular mood-altering potions down through history, from alcohol, opium and marijuana to widely prescribed "mother's little helpers" such as Librium and Valium? Unlike the typical street drug, which sends people soaring and then crashing, Prozac has an effect that is even and sustained. And it seems safer and has fewer bothersome side effects than previous medicines prescribed to lift people out of depression. Prozac is what scientists call a "clean" drug. Instead of playing havoc with much of the brain's chemistry, the medication has a very specific effect: it regulates the level of serotonin, a crucial compound that carries messages between nerve cells. "Prozac makes people feel different without making them feel drugged," notes Kramer.

Patients don't all react the same way, of course; some don't feel a bit better. And many psychiatrists and patients don't agree with Kramer about the drug's transformative powers. "I have my ability to not snap at people back, my energy back, notes a rabbi who recently started taking Prozac for mild depression. But, he adds, "I don't feel like Superman, and I still can't stand parties."

"There's a lot less than meets the eye with Prozac," says Dr. Daniel Auerbach of the Veterans Health Administration in Sepulveda, California. "Nothing changes personality. What gets changed is symptoms of a disease." In other words, Prozac enables a person's true personality, often imprisoned by illness, to come out. Contends Dr. Hyla Cass, a psychiatrist in Santa Monica, California: "I don't think Prozac is manipulating people, turning them into feel-goods. It is correcting an imbalance, allowing people to be who they can be."

But, counters Kramer, doesn't that broaden the boundaries of mental illness to include any condition that responds to Prozac? If a person responds to an antidepressant, does that necessarily mean that he or she is suffering from depression? Kramer questions whether the "imbalances" cured by the drug are always bad; maybe they are just frowned upon by current society. Are the vivacity and blithe spirits often produced by Prozac superior to shyness and a touch of melancholy? Do decisiveness and vigor have more merit than reticence and calmness? Should a business executive who lacks aggressiveness feel compelled to take a pill? Just as ticklish is the question of when a doctor should stop prescribing Prozac. Satisfied customers don't want to abandon the drug even when their illness seems gone. Kramer's book tells the story of Tess, a businesswoman who became more assertive and outgoing after starting to take Prozac for depression. When Kramer took her off the drug, she complained that "I'm not myself." The psychiatrist renewed her prescription, but not without qualms. "You could say you're giving Prozac to her to prevent recurrence of depression," he observes, "but you could also say you're giving it to her to maintain her new personality."

Some patients have mixed feelings about their altered state of mind. Elizabeth Wurtzel, a 26-year-old writer in New York City, began suffering severe bouts of depression when she was 11, and has been on Prozac for five years. Though the medication has raised her spirits, she also finds that it has erased some character wrinkles. "I kind of miss the person I used to be," she says. "I'm much more content with less. The person I used to be was outraged in a way that I'm not anymore."

Wurtzel thinks the drug is becoming too fashionable: "Now I go to parties and everyone says, 'I'm on Prozac too.' You can just walk into a doctor's office and say, 'I think I'm depressed,' and he writes you a Prozac prescription. This should not be a drug for people who sort of feel bad. If they feel bad, they should figure out what's wrong with them." Dr. Herbert Pardes, who heads the psychiatry department at Columbia University, agrees: "I'm reluctant to have people taking drugs just to feel better. People have ups and downs of all sorts -- that's the way life is."

Most psychiatrists argue that while Prozac may be abused, it is still a long way from being overused. A study by the National Institute of Mental Health shows that 40% to 50% of people with major depression are not receiving any kind of therapy.

With so many still going untreated, Kramer's book may do a service by alerting some of them to Prozac's potential benefits. But Kramer may also be raising expectations too high. Says Dr. Glen Gabbard, director of the Menninger Memorial Hospital in Topeka, Kansas: "We should not send patients rushing to their corner pharmacy in hopes of getting a magic chemical that will solve all their problems." For most people, happiness does not come packaged in a pill.

With reporting by Deborah Edler Brown/Los Angeles and Sharon E. Epperson/New York