The SSRI Debate

Background

Following its 1988 release, after a short period of relative obscurity, as the effectiveness of Prozac came to the attention of both doctors and the general public, and after two years on the market, it became the most prescribed antidepressant medication in history. Prozac was heralded as a breakthrough in the treatment of depression in the press, and quickly became a pop cultural icon. Perhaps Prozac caught on too quickly, for the surge in public enthusiasm and the millions of prescriptions issued led many to suspicion. Following a few incidents of violence by people taking the drug, Prozac was implicated as the cause of these tragic events. The media had a second field-day, this time framing Prozac as a pharmacological villian. One talk show aired a program featuring the alarmist title "Medication That Makes You Kill". The Eli Lilly corporation was presented with hundreds of lawsuits claiming the Prozac was responsible for suicides and criminal acts. Prozac had become the victim of a widespread confusion between correlation and causation. The hysteria passed with time, however. Only a single lawsuit against Prozac reached a court, and it was quickly dismissed. This type of sensationalistic journalism nonetheless left the name of Prozac tarnished in the eyes of the public.

Pro-prozac

Millions have been relieved from crippling depression by SSRI antidepressants. Because this class of medications is equally effective as the tricyclics in the treatment of depression, with greatly reduced side effects, which often prevented the continuation of treatment with the older medications, SSRIs have allowed successful drug therapy for many. Furthermore, fanfare surrounding these drugs has greatly increased awareness of depressive disorders and helped to destigmatize the use of antidepressants, prompting millions to seek treatment. SSRIs have also provided new and effective avenues for the treatment of obsessive-compulsive disorder and other anxiety related problems. For those with severe clinical depression and anxiety, the SSRIs have truly been a medical miracle.

Conzac

While SSRIs have relieved countless people of debilitating depression and anxiety, there is another sizable fraction of the patient population taking SSRIs for less severe conditions that may or may not warrant medication. Peter Kramer, in his book Listening to Prozac, first described the use of SSRIs for 'cosmetic psychopharmacology.' Due to their anxiety relieving properties and general action on the serotonin system which causes several peripheral effects, SSRIs have been prescribed for a diversity of conditions such as shyness, premature ejaculation, fastidiousness, general dissatisfaction, and insomnia. While the alleviation of these minor problems constitute another benefit of SSRIs, it raises the question of the use of pscyhotropic medication for the conformation to social norms. Excessive attention to detail and shyness are not diseases, yet they are defined as undesirable by our current culture and are therefore the targets of SSRI treatment. SSRIs, when used in this way, reinforce existing cultural values and normalize those outside a certain range of behavior. For example, someone who is excessively neat may be seen as aberrant in our society and looked upon by a physician as borderline obessive-compulsive, whereas in a society in which such neatness is the norm, such as in Germany, this behavior would not be seen as abnormal. A danger exists that these drugs may be used, and even expected, to eliminate socially defined "bad" tendencies from peoples' personalities.

Such 'abnormal' behavior, as long as it does not hinder daily living, may in fact serve an important function. Anxiety, after all, exists to protect us. It is our bodies way of keeping us ready for important tasks, and the reduction of anxiety serves as a motivating force. Without anxiety, we would have little motivation to do anything we did not absolutely want to do. Anxiety drives us to take care of ourselves and those around us. Although severe anxiety is a problem that should be treated, eliminating anxiety altogether is certainly not desirable. Parallel arguments can be made for unhappiness. While clinical depression is a serious medical problem, unhappiness is a cue that something is wrong in one's life and should be changed. SSRIs, which, in those with severe anxiety and depression, brings the psychological state back into a functional range, run the risk of eliminating psychological cues important in the maintainence of ones life when used unecessarily. With these psychoactive pharmaceuticals, as with so many other technologies, we must be cautious not to do harm in the attempt to do good.

Should Ritalin be used to modify behavior?

Psychostimulant medication been used to correct disruptive behavior in children for over fifty years. Whereas psychostimulants were previously a last resort attempt to amend very severe behavioral problems, the prescription pattern for these drugs has broadened over the past decade, increasing sevenfold. Today, over four million US children begin the day with a dose of these amphetamine-like compounds. The prevalence of stimulant prescription to children--one in five children take the drugs in some areas--has raised concern among many that stimulant medication is being prescribed to some children not to treat a legitimate psychiatric condition, but as a convenient means of dampening naturally active behavior.

Allowing Children to be Normal

Proponents of psychostimulants see the drugs as a way of allowing children who have trouble concentrating to fit in the with other children. ADD kids may be perform poorly in school, be naturally overactive, and have trouble understanding and following rules, all which may cause them to be singled out by their peers. This may hinder social development or prompt the child to garner positive attention through misbehavior, causing further problems. Ritalin advocates contend that these drugs merely give ADD children a fair chance. Kids with ADD are not less intelligent than other children; however, they cannot focus on schoolwork and so perform poorly. In many cases, stimulants have turned weak students into high achievers and made severely disruptive students cooperative.

Born to Explore?

Many see the prescription of psychostimulants as a crime against children. While most groups agree that stimulant prescription is warranted in some cases in which it students have genuine attention difficulties, stimulant opponents view a large portion of these cases as a convenient way for parents and teachers to eliminate disruptive behavior. Since ADD is often concomitant with high intelligence, many fault unchallenging schools as the cause of poor performance and lack of concentration. ADD is the mark of the overactive and creative mind, advocates contend.While ADD kids may not perform well on traditional academic tasks, they make excellent inventors and entrepreneurs and may ultimately benefit society more than well conforming children, as in the cases of Mozart, Hemingway, and Teddy Roosevelt, who displayed classic ADD symptoms. By medicating these kids, we are stamping out their creative and exploratory spark and robbing society of a valuable element.

A Conflict of Rights

Teaching children is difficult enough without having to deal with disruptive students. With teacher salaries absurdly low, the waning supply of teachers is giving those willing to do the job increasing clout with school districts. And school districts, at the request of teachers are demanding parents to put their disruptive children on stimulants, often with threats of expelling the student, or worse, reporting the parents to the child protection services for denial of medical care. Numerous parents have chosen to withdraw their children from particular school districts rather than give them psychostimulant drugs. In these cases, the rights of the parents to determine what is best for their children come into conflict with the rights of the school to provide a learning environment free of distraction and disruption.

The controversy over stimulant medication demonstrates the delicate balance that exists between the benefits of technology and it potential hazards. Any technology that performs a useful function to society can also be subject to abuse. And stimulant medications certainly follow this pattern. While stimulant drugs are a safe and effective means of treating legitamate cases of attention deficiet disorder and is advisable by doctors in many cases, it is not the only treatment, and avenues such as counseling or modifying lifestyle choices such as diet and exercise should also be explored. Since ADD, like all psychiatric disorders, cannot be positively diagnosed using a clinical test, it very difficult to separate straitforward bad behavior and poor performance from biochemical disorder. Addtionally, because psychstimulants will improve the concentration of anyone, the positive results, even from improper diagnosis, are taken as conformation of a problem. Before allowing their child to be put on psychostimulant drugs, parents should be careful to educate themselves about the disorder and available treatments and consult a reliable medical professional.

Chris Liverman [liverman@grinnell.edu]