Don't Worry, Take Prozac?

A Bush campaign worker was caught in a gaffe that was not only tactless, but also uninformed:

"A campaign worker for President Bush said on Thursday American workers unhappy with low-quality jobs should find new ones -- or pop a Prozac to make themselves feel better.
"Why don't they get new jobs if they're unhappy -- or go on Prozac?" said Susan Sheybani, an assistant to Bush campaign spokesman Terry Holt.
The comment was apparently directed to a colleague who was transferring a phone call from a reporter asking about job quality, and who overheard the remark.
When told the Prozac comment had been overheard, Sheybani said: "Oh, I was just kidding.""

Ms. Sheybani is guilty of making the same mistake that many patients who come to psychiatrists make--thinking that a pill such as Prozac(or Paxil, Celexa, Zoloft etc. etc.) will make all their problems go away somehow. These drugs are some of the newer antidepressants (often referred to as "SSRI's", or Selective Serotonin Reuptake Inhibitors--which describes what they do in the synapses of the brain). They are extremely popular and some of the most frequently prescribed medications; and common belief holds that somehow these drugs are "happy" pills--designed to make you feel happy about your life. This is completely false.

People who benefit from these drugs are those who have "clinical depression", and "clinical" means that the depressed feelings are something more than just being "sad" or "down" about things like we all are at times. People with a clinical depression have a "biological vulnerability"to being depressed, and it is thought something is not entirely stable in the way their brain is functioning. Without medication, people with this physiological vulnerability are unable to get back to normal functioning. The unasked question is: how does the brain get off the track to begin with?

This is where (1) events in a person's life (some of which they might have no control over; (2) behavioral patterns (some of which they only think they have no control over); and/ or (3) choices that a person has made--all come into play. In many, if not all cases of depression (clinical or otherwise) the stimulus for the depression is outside of the brain. And that means that dealing with the person's depression requires more than just giving them a pill. It means helping them learn how (1) accept things they cannot change; (2) change maladaptive behaviors and (3) make better choices in their lives. This is referred to as "empowering" the individual--a term I really dislike, since it implies that somehow I am the one who gives them this power. The truth is that I do no such thing. As adults, they have had the power all along.

Even individuals who have a clinical depression and a strong biological abnormality as the basis of their illness can benefit from learning new cpping behaviors/skills that help them to deal with their illness.

An example of these points, that I regularly present to my medical students is the "battered woman" who comes in to see me and tells me she is depressed. In addition to her bad marriage, she may also have a family history of depression or other mental illness, which might clue me into the possibility of her possessing one of those "biological vulnerabilities". I may decide that her symptoms are severe enought that they might benefit from taking one of the antidepressants. But in addition to prescribing the medication, I also make sure she understands that just because she is taking this drug doesn't mean her husband is going to stop beating her. She is (and this is the hard part) going to have to take responsibility for the situation she is in and make some changes in her life. Otherwise, all the drugs in the world will not make any difference in the long run. The medicine can help her ability to cope with life and give her the energy to make the changes she needs to make, and that is no small thing - but it is not the only thing needed.

This reality check is very disappointing to most people, who may want things to change, but who are extremely reluctant/scared to actually do anything to make it happen, especially if it means changing yourself. That is hard,exhausting work; it requires an effort of will and a desire to alter the landscape of your reality. Just swallowing a pill every day doesn't alter the outside world. But, honestly assessing your situation; re-evaluating your choices , and making changes in your behavior, you can make a big difference in your environment.

In the case of the battered woman, if she decides to alter her circumstances (e.g., by leaving the abuser and taking advantage of the supports available for women in this situation; or insisting on marital counseling; or demanding a halt to the husband's behavior) then she has begun the most important part of her long-range recovery from depression. I am not saying this is easy. In fact, it is often quite difficult (and even dangerous at times for some women). They feel damned if they do try to get out of the battering situation, and they are certainly damned if they choose to stay in it. But it is a choice they must make.

Likewise, the people Ms. Sheybani was referring to--those who are unhappy with their low-quality, low-paying jobs. Most of these people are not really clinically depressed in the first place-- they just don't like what they are doing. This does not, however make them "victims" of the job. They are perfectly capable of making the decision to change their job, and then doing what they have to to implement that decision. To get something better and more to their liking might require that they go back to school; or get some new training; or simply just start looking around for something they think will be better for them. But taking Prozac will not make them suddenly happy with their job. If a doctor gives them a drug, without also encouraging them to take responsibility for their own life, that doctor is reinforcing their sense of helplessness and encouraging them to become a victim of life's circumstances. Taking responsibility for their own happiness--instead of waiting for someone or something else to make them happy (like a drug; or the government; or their spouse)--at least offers the potential for changing their lives.
In both cases (the battered woman and the unhappy worker) it is a matter of making hard choices, taking responsibiity and changing personal behavior.

The political implications of all this are simple. The government (just like the psychiatrist; just like Prozac) cannot make you happy. Most programs that try, end up being counterproductive and encouraging victimhood and helplessness, thus making the program self-propagating and ultimately, worse than useless for both the individual and the society. In a capitalist democracy, dedicated to indivdual freedom and personal responsibility and reward; the pursuit of happiness is already open to all citizens. Help is available to level the playing field--so that those with the biological risks; and those with the low-quality jobs can work hard and make the choices that will get them where they want to go in life--but nothing is guaranteed; and success is not preordained. Happiness may just be a by-product of working toward your goal to the best of your ability, whether you get there or not.