I know a psychiatrist who took antidepressant medication (plenty of us do, though few admit it). When at his best, he imagined himself a poet, someone who wore a white coat in sunlight and composed quatrains by candle.

Then, in the mysterious way that depression descends, he became ill. Still, the poems were passionate.

For years, he had been prescribing Prozac and its many cousins: Zoloft, Paxil, Celexa, Luvox. He knew how the drugs worked, and that they worked well.

Within weeks of starting one himself, his sleep and concentration improved: Circular worries grew quiet, despair disappeared and old energy returned. He remembered what it was to think well of himself.

A few months into treatment, he noticed -- doubtfully at first -- that he no longer felt like writing. The words did not seem worth laboring over.

Without fanfare, without farewell, the desire to put words to paper had just disappeared.

So had deep emotion of almost any kind. It was a quiet shock. He had heard of such a thing happening, but there is nothing like experience to vitalize any theory.

Fifteen years ago, Prozac was marketed as a medication with a single, elegant mechanism and no side effects to speak of.

Professionals, and their patients, greeted it with wild hope. Prozac promised permanent renovation of the self in four to six weeks -- no money down, with custom-made cabinets and granite counter tops.

The drug quickly became a celebrity; a book with Prozac in the title was nearly as sought after as a prescription.

It worked for depression, was less toxic to the heart than older classes of drugs and was so simple to prescribe that even surgeons could take credit for psychiatric cures.

The first side effects, when they finally emerged, were bothersome but bearable -- insomnia, nausea, sweating. Next, patients began to complain, in office whispers, of sexual problems.

You could have granite counter tops, it turned out, if you traded them for libido, erections and orgasm. (In a fine example of smashing lemons into lemonade, this led to a new marketing strategy: Prozac as a remedy for premature ejaculation.)

It now appears as though a majority of patients on antidepressants experience sexual side effects to some degree. Some of the sexual side effects were treatable by dose reduction, adding other medications, switching antidepressant class or using herbs.

Other patients decided to forego sex as they once had known it. Life without the devastation of depression was worth the price.

Then the next generation of side effects came into view -- or rather, they disappeared from view, for they are identified more by their absence than presence.

On Prozac and its family members, some patients began to notice a lack of joy as well as sadness. They noticed in themselves a strange emotional denseness; not a black hole (as depression is) but a wall so thick that only the strongest stimulation could penetrate it.

If depression is a kind of excruciating hypersensitivity, this was an indiscriminate desensitization, a bland state of being.

Writers were uninspired to write, nature lovers complained that they no longer could enjoy colors in the woods, and people of formerly passionate opinion just did not care enough to argue.

Researchers got right on the explanation. While Prozac (and others in its class of antidepressants) increases specific chemical transmissions (or neurotransmitters) in some parts of the brain, it inhibits others elsewhere: More serotonin here is balanced by less dopamine there, and less dopamine, particularly in the frontal lobes, decreases motivation, drive, pleasure, intensity.

The cursed feelings are gone, but so are the blessed ones.

Psychopharmacologists tried to create balance artificially. They added medications to broaden, and enrich, the antidepressant's action and to compensate for the dopamine deficit.

For those who had hoped to relieve their depression with a single pill, it was discouraging. Sometimes the polypharmacy worked, but other times -- and there was no predicting -- the muses remained mute and the colors continued to bear dull resemblances to former colors.

It was like existing less.

Which state of being is more to be feared: life with depression, or life without nuance and feeling? When you cannot see to the next day, when the very concept of future is intolerable, no price seems unreasonable.

Long before Prozac, classic psychoanalysts worried that medication allowed patients to cheat the process of recovery by offering relief without self-reflection; they thought drug treatment was too easy.

In fact, patients freed from the weights of depression have more energy for insight.

The graybeards were simple-minded -- or perhaps, had not suffered enough themselves. Any path away from pain has merit, and Prozac saves lives. But sometimes -- and here is where the cheating occurs -- it goes on to lessen them.

My colleague (against the advice of his own psychiatrist) has stopped his antidepressant and hopes for the return of the muse.

Someday, there will be another class of medication that does not force him to make this particular choice, though it probably will force a different one.

Meanwhile, no one can advise him on the way to make peace with his life. We only have options, more and more of them, and all are equally imperfect.

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Dr. Elissa Ely is a psychiatrist at a state hospital in Massachusetts.

Copyright Los Angeles Times  / latimes.com November 25 2002

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