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    The Price of Prozac
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Healing The Soul in the Age of the Brain
Becoming Conscious in an Unconscious World

by Elio Frattaroli, M.D.

The following is a revised version of an editorial that appeared first in the Chicago Tribune on August 19, 2001, and then, in a different form, in the Philadelphia Inquirer on August 21)

The Price of Prozac

Prozac has gone off patent. Cheaper generic now available.

Eli Lilly estimates that more than twenty-two million Americans have taken Prozac already, so I doubt that anyone was waiting for the price to go down before getting their depression or anxiety treated. But I do wonder how many women will keep taking Prozac packaged as Sarafem when they can get generic Prozac for 30 to 40 percent less. Lilly is counting on quite a few.

It was just last summer that Lilly got patent approval from the Food and Drug Administration to market the Prozac formula (fluoxetine hydrochloride) with a new color (pink pills instead of green), under a new name (Sarafem), for a new use: treating PMS. Actually, Lilly calls it PMDD (premenstrual dysphoric disorder) but the line between the two is fuzzy at best, and neither is an officially accepted medical diagnosis.

So leaving aside the interesting question of why the FDA would endorse such a marketing tactic, why does Lilly expect that women will continue to pay bloated prices for Sarafem when, if they simply admitted that they were really taking Prozac, they could get the generic so much cheaper.

The logic is simple: Lilly knows that most people would rather not have to admit that they are taking Prozac. Prozac is for mental illness but Sarafem is for PMS (sorry, PMDD), which is a physical illness and most of us feel a lot more comfortable being treated for physical illness than for mental illness. So much so that the U.S. Surgeon General, the American Psychiatric Association, the pharmaceutical and managed-care industries, and the National Alliance for the Mentally Ill all agree that the way to destigmatize mental illness is to convince us that it is really a physical illness, just like diabetes.

But apparently we are not convinced because the stigma remains. Most of us would find it much harder to admit to being dependent on Prozac than on insulin. We have an uneasy sense that mental illness reveals something bad, or shameful, or threatening about us that we need to keep hidden, even from ourselves (for instance, by telling ourselves that Prozac is Sarafem).

Back in the day before Prozac, being mentally ill used to mean being emotionally disturbed—unsettled, unbalanced, overwhelmed by passionate fears, excitements, joys and griefs that we would rather not feel but are unable to control or ignore. Following Freud, we understood psychiatric symptoms as a failure of repression, our unconscious emotional “dark side” trying to force its way into consciousness against our will.

But Prozac made it so much easier to control, ignore and repress all disturbing emotions. By making our symptoms go away, it convinced us that mental illness was chemical rather than emotional and that the Freudian unconscious didn’t even exist. Well, almost. Prozac could never make the stigma go away. It remains as a stubborn reminder of what we are just as stubbornly trying to hide from: the powerfully disturbing but vitally passionate dark side of our own inner lives.

The stigma reminds us of what, at a gut level, we already know: that mental illness is not like diabetes. In mental illness, we become depressed or anxious about something. We hallucinate or become paranoid about something. Diabetes, like physical illness generally, is not about anything. It just is.

Of course, there is a physical dimension to mental illness. But mental illness is never only physical. Take the woman in the Sarafem commercial suffering from PMDD who has a mini-meltdown in the supermarket when she can’t get her shopping cart unstuck. Her agitation is influenced by hormones but she is clearly agitated about something. Consciously, it is about the shopping cart. Unconsciously, it could be about her feeling oppressed by a family, a society and an internalized value system that expects her to be a happy shopper.

Or take “our son the doctor” who becomes so depressed that he can no longer work as a doctor. Biologically, he might have a chemical imbalance but unconsciously he could be depressed about feeling obligated to spend his life trying to please his parents when he really wanted to be a musician. Or the woman who has severe panic whenever she tries to leave the house alone. Her symptom (agoraphobia) may be influenced by her genes but unconsciously, she could be anxious about being too independent, autonomous, “liberated.”

PMS, depression, agoraphobia and other so-called psychiatric disorders are not physical illnesses. They aren’t really illnesses at all, but symptoms of a deeper mental illness that is both chemical and emotional. Like the physical symptoms of fever, cough and pain, they are part of a healing process—the unconscious trying to become conscious, calling attention to what we have been trying to keep hidden so that we can understand and accept it as part of ourselves.

How much is it costing us to make symptoms like this go away while pretending they are not about anything? What price are we paying to have a chemically liberated nation of happy shoppers and successful compliant children? In monetary terms the price of Prozac is going down. In human terms it has never been higher.

Elio J. Frattaroli, M.D. August 22, 2001