Prozac Lessons: 5 Questions for drug historian David Herzberg

Herzberg discusses the history of “mind medicines” like Prozac and parallels between antidepressants and psychedelics.

David Herzberg started his career as a cultural historian, and grew interested in the idea that what people think can be more important than what is true. That led him towards the gulf between the world of drug advertisements and reality. In particular, Herzberg began to study drugs marketed to ease depression, anxiety, and psychological suffering. His first book, Happy Pills in America, was published in 2009  and focused on the rise of Prozac and antidepressants. Herzberg, an associate professor of history at the State University of New York at Buffalo, has also studied opioids, and the promises of psychoactive pharmaceuticals. The Microdose spoke with Herzberg about the history of “mind medicines” like Prozac and other selective serotonin reuptake inhibitors (SSRIs), and parallels between those antidepressants and the current growing popularity of psychedelics.

How were antidepressants marketed in the past, and how does that affect our current understanding of depression treatment?

Antidepressants are a malleable category; it hasn’t always meant the same thing over time. There were predecessors to current antidepressants, like SSRIs. For example, what were known as the “minor tranquilizers,” or benzodiazepines, which were introduced in the 1950s and used through the 1970s. They were considered useful for what at the time was understood as a psychosis. The king of benzodiazepines was Valium, which, at the time, everyone and their sister were taking. I say that because it was women who were primarily prescribed this, and in the 1970s, with the rise of second wave feminism, it began to lose its luster. Feminists latched onto it as a political symbol. Medical science says these women are unhappy because they have anxiety, but why are they unhappy? Perhaps because they’re being oppressed. The drug was also a perfect symbol for what sexism does to white, middle-class women being prescribed Valium: the drug dulls you, makes you passive and accepting. 

So that sets the stage for a new kind of medication: SSRIs like Prozac, which came out in the U.S. in 1987. It was a new class of antidepressant, and also a new story about antidepressants; people were excited about it because it was marketed as a step forward in specificity. The new story went like this: old antidepressants worked on all the neurotransmitters, which did stuff you wanted but also stuff you didn’t want. Prozac, on the other hand, was like a scalpel. The model of what depression was is the idea that your brain could run out of serotonin like your car runs out of gas, and Prozac supposedly just worked on serotonin. Of course, we now know that was totally wrong, and even neuroscientists at the time were aware that this simple story wasn’t accurate. But it was a useful fiction for helping the public understand the drug and for helping companies market it to the public.

The most important and the most lasting impact of Prozac’s popularity is the way it asked people to think about depression as something that takes place entirely within someone's brain, that it’s a material phenomenon and that can be fixed by altering brain chemistry instead of recognizing that the human experience is irreducibly social and complex. That model of depression ignores society, justice, and human complexity to try to find a shortcut to sculpt people.

Currently, people have high hopes for using psychedelics to treat depression and anxiety. How do you see these drugs fitting into the history of other mental health treatments?

There’s been an enormous amount of money invested in psychedelics as people hope that they can be the real Prozac in the same way that Prozac hoped it would be the real Valium and Valium would be the real barbiturates, which would be the real morphine. There’s a long history of hoping that maybe this time, it’s not so complicated; maybe there is a simple switch to change people without having to change any aspect of their life besides what drug they’re taking. Of course, there are people who are pushing in the other direction. The whole point of psychedelics is that it's going to require days, with experienced guides, preparation, and follow-up. It’s not going to be something you can produce a billion units of at a time and sell as a consumer product. That debate is happening but between incredibly unequal sides, as one is heavily capitalized.

Here’s an analogy: take the problem of people drowning in backyard swimming pools. You can respond to this issue by doing basic science research of what happens to lungs when they fill with water. Or you can build fences around pools and teach people to swim. All of those things are important, but what happens when you decide that one solution really matters and you can ignore the rest? 

It seems there’s a desire to eliminate the social aspects of mental illness. You can take a healthy person and put them in the front lines of World War II and on the other side of that experience you might not have a healthy person any more. Circumstances, even at a simple level, matter a great deal. Certain behaviors or ways of being may be fine in one circumstance but problematic in another. So which is “healthy” and which is “ill”? These kinds of questions can’t be answered biochemically, but the dream of being able to answer them through a consumer product — something mass producible, that can be easily and conveniently added to someone’s life without the rest of the life changing — is a grafting of consumer society values onto medicine. 

The reality is that Prozac certainly helped some people, but it also harmed people and skirted past big issues we need to engage with. Perhaps the most important thing it did was that it made some people a bunch of money.

The last two years have seen increased discussion in the psychedelics world about potential harms, from disturbing trips to psychedelic therapy abuse. In what way did Prozac hurt people, and do you see any parallels to the current conversation about psychedelics?

In general, Prozac is light on serious side effects, but a significant number of young people on Prozac had increased likelihood of suicide. Obviously, that’s the worst side effect imaginable for a drug that’s supposed to prevent depression. 

One other risk of Prozac was that it could lead to a failure to attend to the circumstances connected to suffering. If you got Prozac as part of extensive therapy that helped you make changes to your life to help you feel better, that's great. But the dream of commercial medicine is that drugs like Prozac will let us do things faster. When Prozac came out, psychiatry changed dramatically; the amount of time with patients dropped, and some physicians became expert prescribers instead of experts on humans. It’s important to have expertise in prescribing the right medication and dosage. But if the goal is to produce a treatment that can take x number of minutes, and be machine gunned out to turn a profit — which is, sadly, what our healthcare system is intended to do — you’ve opted out of having responsibility for all the other dimensions that are considered part of therapy. That changes our sense of psychological suffering and what health means. 

I’ve heard the idea of giving people potent psychedelics, where the trip is 30 minutes. I’ve even heard about cases where the idea is to give people psychedelics while they’re unconscious so that they don’t need to undergo preparation, since they’ll be tripping while they’re out. That epitomizes the fantasy that we can take a complex phenomenon like a human’s psychic suffering and somehow find an escape route.

Another big topic of conversation in the psychedelics world is the state of research. People are particularly concerned about methodology to assess the efficacy of psychedelics in treating these mental health conditions, and how placebo and expectancy effects could be driving results. What did the clinical trials leading up to SSRIs’ approval look like, and did any similar themes arise? 

The studies leading up to Prozac were corporate fraud. Companies massaged some studies into having a positive effect and did not report negative ones. More recent studies show that Prozac is no more effective than placebo. Some people take that to be harsh criticism, but placebo is 50% effective! That doesn’t mean throw Prozac in the trash; it’s useful info to know.

There’s an important lesson from SSRIs: you simply cannot trust enormously capitalized science. Humans simply cannot separate out their own agendas and mindsets. We've been trying to do these randomized controlled trials, but nobody can pretend that the whole research system isn’t incredibly biased towards positive results. That’s been incredibly harmful; just look at the opioid crisis. With Prozac, studies that showed it was effective should have actually shown it was ineffective.

The second lesson is that those studies are themselves a deeply flawed result of the hope of producing objective data. The randomized, placebo-controlled trials are a useful tool in some contexts but if you look into them for something like depression, you get into bigger questions, like how do you measure depression? If you’re using, say, the DSM-III checklist, where did that checklist come from? The answer is a bunch of old white guys in a room, coming up with a compromise they could all accept. And that becomes the measurement of this incredibly complicated thing. You could say that the story of Prozac is that we don't know how to talk intelligently about how treatments work to ease psychic suffering because we've never fully been able to nail down, medically, what it is. 

Political and cultural forces helped accelerate American acceptance of Prozac. Do you see any similarities between the forces at play in the 1980s, and what’s happening in the world now?

There’s this continued quest to make being a person with money in America feel the way it’s supposed to feel, which is awesome. The goal of American capitalism is to make somebody like me — a person with a white collar job and decent income —  feel good. Our society is designed to create things that increase my convenience, that make me feel better, and it’s a crisis if someone like me doesn’t feel good. This is a particularly 20th century American belief; it isn’t a universal human expectation.

So, how can we deal with human suffering in a way that doesn’t change or challenge any of the things that contribute to it, and maybe even allows us to profit off of them? I’ve noticed that when you read about psychedelics, you’re just as likely to read about their profit potential as you are about their psychological potential. That’s something that struck me as I was doing my research on Prozac, too; half the articles I read were about how much money someone was going to make on it. It’s as much a part of commercial consumer capitalism as it is medicine. 

It’s easy to imagine other ways Prozac could've come into use: by combining it with the removal of structural barriers, or with training and support to help people take advantage of new opportunities. It could’ve become part of a different, larger project of helping people handle misery. The same is true of psychedelics: they’ve been around a long time, but the present moment feels driven by a desire to turn them into a capitalizable thing. That’s what I have skepticism about. That won’t improve people’s well-being in any meaningful way. That’s no sleight on psychedelics themselves, which have the power and capacity to help people. But it seems like the money is trying to make sure that the way we encounter them is the way we encounter everything else. 

This interview has been edited and condensed for clarity and length.