In the fall of 1987, a story appeared in the business section of The New York Times about a new antidepressant drug, fluoxetine, which had passed certain key government tests for safety and was expected to hit the prescription drug market within months. Just this brief mention in the Times about the prospective appearance of the new, perkily named Prozac propelled Lilly shares from $10 to $104.25—the second-highest dollar gain of any stock that day. By 1989, Prozac was earning $350 million a year, more than had been spent on all other antidepressants together in 1987. And by 1990, Prozac was the country’s most prescribed antidepressant, with 650,000 prescriptions filled or renewed each month and annual sales topping $1 billion. By 1999, Prozac had earned Lilly $21 billion in sales, about 30 percent of its revenues.
Back in the 1970s, Prozac didn’t look so promising when Lilly, a company then known for producing antibiotics, began working on it. Serious depression—which warranted hospitalization, perhaps electroshock, or a gaggle of psychiatric medications, many with appalling side effects—was viewed as a debilitating but rare condition, thought to affect only 1 in 10,000 people. Less paralyzing depression symptoms were regarded mostly in psychodynamic terms, such as “depressive reactions” or “depressive neuroses.” After all, what relevance could a “chemical imbalance” possibly have for issues like “retroflected anger” or “oral introjection” or “identification with the lost object”?
Lilly had planned to market its new drug for hypertension or maybe anxiety, but fluoxetine just didn’t seem to work at lowering blood pressure, and the tranquilizer market had nose-dived after people had learned to their horror that Valium and Librium—“mother’s little helpers”—were turning perfectly respectable middle-class ladies into addicts. Lilly then tried using fluoxetine as an anti-obesity agent, but that didn’t work either. Nor did it relieve symptoms of psychotic depression: it actually made some people worse.
And then, according to psychopharm folklore—maybe because they had nobody left to try it on—they gave fluoxetine to five mildly or moderately (stories vary) depressed people, all of whom then felt much better. Bingo! Therein lie the origins of this little med with the zippy brand name, which set in motion a vast antidepressant empire, as well as the longest, most remunerative gravy train in psychopharmaceutical history. Prozac begat a dynasty of selective serotonin reuptake inhibitors (SSRIs) with their tongue-twisting generic and user-friendly brand names—fluvoxamine (Luvox), paroxetine (Paxil), escitalopram (Lexapro), and so on. They, in turn, were followed by the “atypical antidepressants,” including bupropion (Wellbutrin), vanlafaxine (Cymbalta), and mirtzapine (Remerona). By 2008, 11 percent of Americans (25 percent of women in their 40s and 50s) were taking one of about four dozen brand-name antidepressants. These antidepressants were the most commonly prescribed medications in the country (now, in 2014, they’re a few percentage points behind antibiotics) and brought $12 billion a year to the pharmaceutical companies.
How did this happen—and by what scientific, psychiatric, marketing, sociological alchemy? As it turns out, this wasn’t the first time Americans had fallen hard for a haphazardly discovered, but perfectly legal, respectable, and medically approved psychoactive agent that was easy to take and provided quick relief from certain relatively blurry categories of physical and mental suffering. Over the last 150 years or so, we’ve seen successive waves of mass infatuations with psychotropic drugs—morphine, heroin, cocaine, amphetamines, barbiturates, tranquilizers, and antidepressants. While all these drugs are different, the story arc they follow—their rise, triumph, ascendancy, and gradual decline or sudden collapse—does follow a roughly predictable course.
Opium, Heroin, Cocaine
In the beginning was opium—or its derivative, morphine. Although it didn’t exactly have a “debut” in America, having been part of the social zeitgeist since the late 18th century and a fixture of human history since the fourth millennium BCE, it became far and away the country’s most important reliever of psychic and physical pain. Reaching virtual market saturation by the 1880s, it was as widely, freely, and indiscriminately used for just about every ailment as Tylenol or Advil are today. Recommended by physicians, advertised copiously in medical journals and the popular press, easily bought without a prescription form at the local pharmacy or general store, and available by mail order, opiates were taken in pills, tablets, cough drops, liquids (often mixed with alcohol and cannabis for a really good buzz), and plasters. It was the sovereign remedy for that 19th-century, catch-all disorder, “neurasthenia,” sometimes called “Americanitis,” because it was brought on by the conditions of American life: the hustle and bustle of expanding cities, the frenetic growth of commerce and industry, the feverish competition for money and power, which strained people’s nervous energies to the breaking point.