Universe On The Couch

Today's lesson class is the real story of a unique and well-marketed class of medications, the SSRI's or specific serotonin re-uptake inhibitors.

Our story starts with melancholia, know since antiquity, which is what we would generally now call Major Depression. For what its worth, famous people such as King Saul and Abe Lincoln may have suffered from this. It is a real disorder. But enough on that.

Now Medical science, if you want to call it that, had no real treatment for this. Our usual response is to drug a problem or cut it out of the body. So a drug was sought. Noting mood improvement in tuberculosis patients from a med, they serendipitously found monoamine oxidase inhibitors. This class works by inhibiting an enzyme that breaks down brain chemical called neurotransmitters. So more good stuff is in the brain and helps mood. Super Duper except all sorts of nasty side effects. The worst being the cheese effect where a certain chemical found in many foods and drink (red wine) causes a dangerous increase in blood pressure. You see, our wonderful drug inhibits good stuff too.

Then shortly after, another serendipity breakthrough. A compound developed to treat psychosis chemically similar to did not work for psychosis, but instead helped mood. So long cheese death. Hello dry mouth, sedation, constipation, weight gain,... (Actually much of this was with previous drug class too). Patients had difficulty staying on them and it was difficult to get adequate dosing. These tricyclic antidepressants worked by keeping those same chemicals out in the brain fluid instead of being sucked up in the cells. One more problem: A month's supply of them in overdose blocks heart conduction. Not good in a suicidal person.

Then a wonderful man at Eli Lilly (I met this guy, pleasant and new egotistical scientist) who took on the challenge of developing a substance that was specific to serotonin, one of many brain chemicals. This way you could get rid of many of those frustrating side effects. The birth of Prozac.

And this stuff was great. Suddenly many people were effectively treated in short order. Some were fully cured so to speak. Most were helped to some degree. I loved it. We could really help people. I had many success stories. We all did.

Prozac became a celebrity. News magazine covers. TV coverage. Even books.

Then the backlash. The evil Scientologists (why is science in that word?), always in hate with psychiatry and especially medication, invented some BC front organization to slander it. Sounds like Swiftboat Karl? The suicide thing made its first appearance. Then some psycho paranoid guy went postal and was on it. I read the case, seriously doubt Prozac had anything to do with it. But the lawyers saw a big money target.

Now it was apparent that there were some problems to me and my colleagues. Some people got energized, others sedated. Simple, change the timing to bedtime or first thing in the morning. The bowels moved rather quickly. Not a problem for many in Constipation Nation.

Yet the lingering problem of that sex thing. Serotonin is anti-sex. Some libido issues in both sexes. Difficulty climaxing for both sexes. Even erectile issues in some older males. Less intense orgasms too. Not good in treating a population already with higher incidence of sex issues. To date all sorts of remedies (more drugs) have been tried. None really works. Most are OK with it since it helps their depression so much.

Then we found all sorts of things could be treated. Obcessive-Compulsive Disorder for sure. Something non-addictive for anxiety. Good for Bulimia if they don't barf it up. And we even gave some complicated name for severe PMS so we could diagnose and medicate.

Of course the competitors all raced into the fray. This is typical. One company comes out with a blockbuster using a novel mechanism and the me-too's follow. First was Zoloft. I welcomed it for two reasons. First it didn't have all the bad press Prozac was getting. The expectations and beliefs about a medication have much to do with its effectiveness and tolerability. Second was it had a much shorter half-life, meaning it was eliminated faster from the body. A good thing for changing meds I thought, but now see advantage of slow elimination to reduce effects of discontinuation: Agitation, insomnia, dizziness,... The others (Paxil, Lexapro, Celexa,...) offer no real advantages. Everyone is individual in their brain chemistry, so one of the newer ones may be better for them.

So where are we now? Fluoxitine (Prozac) has gone generic-meaning cheap. Of course we have re-packaging as a pink pill to expensively treat PMS. The other SSRI's are still on expensive patent. The old drugs still work. Buproprion, which works on another brain chemical, is also generic, and lacks sexual problems. Both chemicals are effected by some newer medications. These may be the drugs of choice in the future. We will see.

So there is our tale. Observant doctors finding new solutions. A drug company comes through with progress. People are greatly helped. A start is born. The copy-cats follow. New stars may be out there now. Will a new med be the best yet? It will eventually happen. They certainly look good. The question right now is whether the new combined mechanism antidepressants are the next Michael Jordan or just a Kobe Bryant.