Take the capsule in the green box first, then, starting at the correct day, follow the arrows. It’s late in the summer of 1997, I’m twenty-eight years old and sunk in a depression such as I’ve never known but have always feared. On the way to this low-pressure extreme – addled, immobile, quite sure I will die soon – my emotional mercury must have fallen way past the range of normality, but who knows when. A shamed and shut-in childhood, the deaths of my parents when I was an adolescent, the usual twenty-something disarray for which I was unusually ill-equipped: none had yet brought me here. Here, that is, from Dublin to a glum, rented room in an English cathedral-town university, where I am about to pop my first 20 mg of Prozac from its blister pack.
In the short term, the reasons for my breakdown might have been obvious: the unravelling of a relationship, the departure of the friends I’d made during my first year in England, the drawn-out catastrophe of a research degree it seemed I might never finish, my failure to fill the out-of-term months with paid employment. My Icarus fall came at the height of summer, when all remaining resources melted away. In June, I was still functioning, still making plans for my PhD, though I could not write a word. In July, I did little but weep and complain and lie awake till dawn, finally dragging myself from bed in the middle of the afternoon. In August, I embarked on solitary adventures with a Stanley knife, but only scraped the skin off my arms.
Long term, I had a problem with the long term; I believed that being an adult meant growing up and getting ill. My mother’s depression had been a constant from the time I was three years old, and she died when I was sixteen. Mental illness – nobody I knew said ‘mental illness’ in the 70s, or even 80s – seemed like my secure inheritance: I told myself often that I would be next. Depression was familiar (depressingly so) and at the same time terrifying, second only among my fears to the autoimmune disease that carried my mother away at fifty. I would do many things to delay the inevitable, to put off admitting I too was depressed. Burying myself in academic work; drinking away my mid-twenties (but then who didn’t?); reeling from one fraught relationship to the next and refusing to account for my actions, my strangeness. I did no recreational drugs to speak of; later I discovered certain friends kept their drug use from me, thinking self-medication would do me no good.
Through the tears there came at last a late-night admission that yes, I must be depressed and should take myself to the university’s medical centre. I sketched for my GP the shaky outline of my predicament, described the slow fade-to-black of my secluded summer. The doctor arranged several weeks with an in-house counsellor – this was soon extended to a year with a psychotherapist, off-campus. And quite as I’d expected, she wrote me a prescription for Prozac. I remember that my heart leaped, for the first time in months.
What did a lost boy like me know about Prozac? Even two decades ago, the drug had been everywhere for years, though I didn’t know a soul who was actually on it. To appreciate how ubiquitous the image and idea of Prozac were by the middle of the decade, just google the magazine, book and newspaper covers – they appear scattered with green-and-white capsules which have sometimes artfully split in two and spilled their powder. There is scarcely a more 90s visual cue or cliché; it was already on the cover of New York magazine in December 1989: ‘Bye-Bye Blues: A New Wonder Drug for Depression’. Consider Newsweek in March 1990: above a desert landscape, a huge capsule floats among clouds like a benign UFO, bearing towards mankind its cargo of placid cheer. I had read the UK equivalents of these articles: Sunday-supplement profiles in which Prozac was treated like a celebrity, and the celebrities taking it were just incidental players. Journalists spoke of the neurotransmitter serotonin, on which the drug was said to act, as if the stuff had been staring science and society in the face all along. (Prozac was, is, one of several selective serotonin reuptake inhibitors, or SSRIs. Serotonin is known to be involved in regulating digestion, appetite, sleep, mood and cognition; but the precise biological effect on mood disorders of altering its action or its levels is still quite unknown.) Everybody now spoke as though at last, after decades of shock therapy, debilitating or addicting drug treatment and a stigma that psychoanalysis had done little to dispel, the late twentieth century had simply discovered a cure for depression.
We learned, my generation, to accept and then righteously defend the idea that depression derived from a ‘chemical imbalance’. This seemed like good news for the depressed: a group that would at some point include, we were informed, fully one tenth of the population. What we had not been told was the prehistory of Prozac, which complicates the dominant story at the height of 90s boosterism. The drug, fluoxetine, was developed around 1970 as a treatment for obesity and high blood pressure, but it did little or nothing for either. It did, however, seem to have an effect at the anxious end of moderate depression, and so eventually it was repurposed as an antidepressant and branded as Prozac. Interbrand, the company tasked with giving the drug its public name and face, had previously worked for Sony, Microsoft, Nikon and Nintendo. Its launch in 1987 had demanded (the magazine stories never said) some redefinition of depression itself. Prozac did not work at the catatonic extreme of bone-deep and often lethal melancholia, and so in the process of its preparation for the market a milder category, ‘atypical depression’, was emphasized in the literature directed at clinicians. Malaise, anxiety, lassitude, fatigue, a generalized lack of ambition and verve – these too were symptoms of depression, and in fact might point to the illness quite as reliably as despair, withdrawal and a desire to die.
Media stories about Prozac tended to focus on those patients who hadn’t thought they were depressed, whose vague sense of disquiet or disappointment had so far passed as glum normality. Some blurring at the edges of the definition of depression meant legions of the high-functioning unhappy could benefit from the new drugs. This was the import of Peter D. Kramer’s Listening to Prozac, published in 1993: the drugs could make you better than well. Kramer’s book was the source for some of the feeling that the new wave of antidepressants might turn us into other people, people whom we might not want to be. This was the crude set of questions now posed: if Prozac and the other SSRIs did away with ordinary unease, what was left of you per se? What else might evanesce along with sadness? Realism? Profundity? Scepticism? Irony? The milder, more productive kinds of melancholy? The very need to think or write or make art? Added to all of this before long were reports of suicides among patients on Prozac. And a feeling that even if the media-conjured extremes – psychic cure-all versus thalidomide-scale disaster – were false, there was something not exactly sane about the spread of a Prozac culture.
All of which is to say that opening your first package of the drug in 1997, you could still feel yourself very much in the cultural moment, despite or because of the dark wing-flickers of doubt on an otherwise sunny horizon. I took my daily ration not eagerly but with an oddly energizing sense that many of us now were embarked on this experiment, and it might fail. I can’t deny that among all else I felt darkly glamorous with that blister pack in my hand.
I’d grown up hearing the names of drugs often, watching my mother handle brown-glass bottles of tranquilizers, antidepressants and the numerous pills she took once she was diagnosed with scleroderma, the disease that killed her. Long after she was gone I would still find stray tablets she’d lost behind cushions in the sitting room or in the corners of kitchen cupboards. Always the small green ones – what were those for? (Snapshot of my drug awareness, aged eleven. It’s August 1980 and I have misheard a line from David Bowie’s ‘Ashes to Ashes’. Maybe because I get that Major Tom’s a junkie, I think Bowie is also singing ‘the little green pills are following me’ – it’s ‘wheels’, not ‘pills’ – and so I’m sitting in my bedroom with my radio wondering: does he have depression too?) When I was very young there was Valium – to which I think she was addicted in the 70s – and then Mogadon, both are of the benzodiazepine family, which from the early 60s began to replace barbiturates as the prescription of choice for anxiety and sleeplessness. I remember, though cannot guess the year, my mother telling one of her sisters how glad she was to be off these drugs.
The antidepressants my mother took must have been monoamine oxidase inhibitors, which had been developed in the 50s. She could not eat certain cheeses, or drink red wine – the consequences might be fatal. Side effects of the MAOIs include hypertension, weakness, dizziness, headaches, fatigue, anxiety. How could you tell any of that apart from the physical effects of depression itself? Every drug she took seemed fraught with collateral suffering. Among the dismal ironies of her last years was an episode of hypokalaemia (catastrophically low bodily potassium), caused by one of the drugs she took for the scleroderma. After years of relief she crashed into depression again – hypokalaemia will also cause hallucinations and psychosis. There was an ambulance in the night, followed by weeks in a psychiatric hospital. I had the sense as a child and teen that my mother lived at the turbulent confluence of chemical tides – she might drown under medicines that were meant to buoy her up.
I paused before I took that first pill to read about Prozac’s possible side effects. Weight loss, anxiety, poor concentration, decreased sex drive, disturbed sleep, ‘uncontrollable shaking movements’, thoughts of suicide, feelings of detachment, yawning – these I had already. ‘Strange thinking’ too. Might I expect these symptoms to become worse, or just persist? And in either case, what then would an improvement in my condition consist of, precisely?
I was most afraid of the physical stuff: the possibility that the side effects would be so painful, tiring or annoying that I would give up on Prozac, and therefore also on recovery. As predicted in the literature, nothing much happened for the first weeks, except that I grew extraordinarily tired. It was no longer the agonizing, alert fatigue of depression itself, but a sleepiness I hadn’t known since I was a small child. Each night I crawled into bed a little earlier. A week or so after starting on Prozac I tried having a beer – it wasn’t entirely ruled out in the patient information leaflet – and found I was drunk and ready for bed again after a pint and a half.
My dreams went haywire. I dreamed I found my mother’s bones in her chest of drawers and laid them out for my father and my two brothers to see. I dreamed I was rotting away, like something out of a cheap horror movie, inside an ornate confessional in a vast cathedral. My therapist had plenty to go on: my unconscious, it appeared, was absurdly intent on dramatizing unprocessed grief and stereotypical Catholic guilt. But it seemed to me that these images came not from as yet unexamined depths but from the chemicals now washing about inside me – I felt virulent, baneful, poisoned.
Some fraction of my being rebelled against the insistence of psychiatric medicine and Prozac mythos alike on the chemical imbalance conjecture. I started reading books about melancholia (from Robert Burton’s Anatomy of Melancholy to Julia Kristeva’s Black Sun) and pinned to a corkboard, above the desk where I kept my boxes of Prozac, a photocopy of Albrecht Dürer’s 1514 engraving Melencolia I, with its winged figure of dejected genius. I wanted to be more than a summary of symptoms and side effects, more than my quantum of serotonin.
And yet I had to admit that, as the weeks passed, the worst of my symptoms had begun to recede. I was no longer harrowed by thoughts of self-destruction. I slept like a baby, albeit a baby with a dream-life out of Edgar Allan Poe. The cadaverous aspect I’d acquired during the summer started to diminish: I looked only skinny and sick. I could speak to my friends and university teachers without my head and hands shaking. Though the concentration required by research and writing was still well beyond me, I was able to go back to teaching. And most surprising, I began welcoming my own company, and the chance in solitude to calmly consider how far my life had fallen into perplexity and confusion.
There were still moments of panic, some arising from the fact that I was on the drug in the first place and did not really know if it was working. An ex-girlfriend, looking back over my behaviour in preceding years – the short and vexed relationships, the impulsive flight from Dublin, my ruinous lack of concentration or commitment – wondered if I might have been manic as well as depressed. I looked at her in horror. But that means I’m on the wrong drugs. Having watched a friend go off her lithium and fall out of university then out of sight, I knew just enough about manic-depressive illness to imagine the worst. It took days to talk myself back down. Around the same time I found myself in London for the weekend having forgotten my pills, and fetched up nervously at a pharmacy to ask what would happen if I missed a couple of days. The answer: very little, almost nothing apart from the fear itself. I had doubts, for sure, but some part of me believed that Prozac was doing its job.
After a year, my GP suggested I come off antidepressants. For a long time, when questioned on the subject, I maintained that I’d recovered, and could only have recovered, because of the combination of drugs and therapy. This had become an ingrained wisdom of the time, and seemed only to be confirmed by the now prevalent prescription of Prozac and the other SSRIs.
By the end of the decade, however, antidepressants had lost all their early-90s lustre. Instead of bourgeois angst, they had come to be associated in the public mind with harried single mothers, the long-term unemployed, the recipients of inadequate mental-health care. Prozac now mostly denoted the failure of doctors to prescribe much else, as well as the fate of those whose depressive reaction to blighted economic circumstance had been crudely and cruelly reduced to a chemical slump. Such perceptions aside, reputable studies cast doubt on claims made about the action of the drugs. Gradually my own belief in their usefulness faded, as I began to see more clearly and without so much self-pity the forces that had brought me to my sorry pass: unresolved grief for my parents, my failure (not unrelated to their passing) to acquire basic habits of self-care or self-reliance, the ordinary rigours of displacement and being poor. Also, pure bad luck. In time, I started to view my brief fling with fluoxetine as a tiny episode in the history of psycho-pharmacologic fashions, to be understood alongside the many pills my mother took and the drugs that people half my age have been given for anxiety and attention deficit disorder.
And now? I went for years, a decade and a half at least, without being depressed. I wrote about it, talked about it, talked myself out the other side of my self-definition as depressive. You could even say I forgot about it for a while. Until, when I was older and unwiser, it returned: depression’s haggard comeback tour of my synaptic territory. This time, sitting in the same medical centre, telling much the same tale in middle age, there was no question of my taking antidepressants; my symptoms were not so bad, and anyway looked to be directly related to recent intimate upheaval, painful decisions to be made. (So I told myself and the professionals. I must have been afraid to squarely face again the reality of being unwell, because I lied to my cognitive-behavioural therapist, and each week told her I was having fewer suicidal thoughts.) But something else had changed, and not only because of all the reading I’d since done about the overuse of antidepressants, their opaque operation and frequent lack of advantage over placebos. No, what stopped me this time from asking for an SSRI prescription was simply and perhaps stupidly my sense that I must face things unmedicated.
I cannot say that I recommend this approach. There is probably some more rational accommodation with antidepressants than mine, and perhaps if I suffered again, alongside the usual dolour and despair, the complete collapse of my productive powers that I experienced in my twenties, I would consider the drugs again. That is, if I found I could no longer write, which seems to me the extreme of debility, I would go back on Prozac, or an equivalent. I realise that is an odd attitude to have arrived at after twenty years, and a luxury of sorts – because I have survived, because I get to write about it – that, as I unboxed those first capsules, I could not have imagined.
Image © Chris Geatch