Blue Dreams

by Lauren Slater

  The aforementioned six-to-eight-week period of the clinical trials isn’t the only problem. Adding to that shortcoming is the fact that researchers performing the trials did not ask patients specifically about sexual side effects; it was only when a patient spontaneously complained that the side effect was noted and logged. Sex, by its very nature, exists in a private realm. Many people are naturally hesitant to tell researchers they hardly know that their genitals don’t seem to be working.

  In 1979, almost a decade before Prozac was approved for the general public, Herbert Meltzer of the University of Chicago’s Pritzker School of Medicine had performed an important study of the drug funded by Lilly. Meltzer measured levels of both dopamine and the protein hormone prolactin (which can cause lactation even in men if levels are too high) in patients before and after starting Prozac. What he found: after patients started Prozac, their prolactin levels rose sevenfold while their levels of dopamine dropped off precipitously, leading to sexual dysfunction. Dopamine is the neurotransmitter specifically responsible for motor movement and for sexual arousal and orgasm. Lab rats with impaired dopamine systems are unable to mate. Studies also show that one way to impair the dopamine system is to raise levels of serotonin in the brain; as serotonin rises, dopamine decreases.

  Meltzer’s study confirmed this correlation between serotonin and dopamine. In fact, the dopamine level of one of his patients on Prozac fell so far that the patient developed a rigid, spasming neck, a clenched jaw, and an unbalanced gait, similar to symptoms seen in sufferers of Parkinson’s, who are also known to have severe dopamine deficiencies. He suggested that the company’s new serotonin booster shared similarities with the old antipsychotics such as Thorazine, which also depleted the brain of dopamine. (You may remember that an excess of dopamine is one theory as to the cause of schizophrenia, and hence one reason—the lowering of dopamine—why the antipsychotics were thought to calm mania.)

  For Bolo, the sexual side effects kicked in almost in tempo with her improved mood. “If I were a guy,” she said, “I’d describe it as having intercourse with a sock on. I don’t think I’m a hundred percent numb, but I’ll bet I’m seventy-five percent numb. I just can’t feel much of anything. There’s two issues. Number one, my desire for sex has diminished to almost zero. Two, if Ryan or I manage to whip up a drop of desire, I can’t have an orgasm. There’s no way. No amount of stimulation—soft, slow, hard, fast—will do it. I can’t reach that peak.”

  Bolo and her husband were deeply different in their personalities and proclivities. Ryan worked as a banker. He was a man of numbers, a man who solved problems by breaking them down into their component parts, while Bolo, as a painter and a social worker, looked for the emotional undertones, the current beneath the current, and used her intuitive skills to come to comprehension and to solutions. This radically different problem-solving style often strained the relationship, and when conflicts came up, they either escalated into fights or were simply left dangling. The bedroom had always been the one place the two of them could join together in some sort of shared language. Sex was one of the few areas where they could communicate effectively, wordlessly. It bridged gaps in the relationship and acted as a salve. That language was gone now and the relationship was suffering because of it.

  “If he touches me,” Bolo said, “I feel something jump inside of me. I’m scared because his touch does nothing for me at all anymore. I turn away from him. Hurt gets heaped onto hurt, and our fights fester.”

  Numbness

  For many patients, Bolo among them, the feeling of numbness isn’t just sexual. “On Prozac, far fewer things bother me,” Bolo said. “I’m like a Teflon-coated pan. What would have stuck to me before now just falls off me. I’m more superficial than I was before. I saw a movie the other day with a friend. Off Prozac, I would have cried at the end. On Prozac, I’m dry-eyed. Everyone else in the movie theater was weeping except me. I call it the ‘so what’ side effect. It worries me a little, but on the other hand, I’m so relieved not to be depressed that I’m willing to live with what I call my ‘Martha Stewart self.’”

  Bolo is far from unique in her experience of the “so what” side effect of Prozac. Many patients either comment on or complain about the way Prozac and other serotonin boosters lacquer their world, blunting their responses and putting them at a remove from the intensity of living. No one knows for sure why this occurs, but some theorize that it is the result of damage done to the serotonin system itself, leaving the patient with a restricted range of emotions to express. Psychiatrist Joseph Glenmullen, a clinical instructor in psychiatry at Harvard Medical School, compares Prozac to the now off-the-market diet drug Redux, which was also a serotonin booster and on which, unlike Prozac, many studies of side effects have been done. Redux, when fed to lab rats, damaged the serotonin neurons, burning away their axons and, according to Glenmullen, “destroy[ing] the elaborately branching tentacles of serotonin neurons as they reach[ed] out to communicate with other neurons.”

  Yet some researchers have hypothesized that this pruning effect of the serotonin boosters may in part be the very thing responsible for their efficacy. The frontal lobes of the brain, in their size and circuitry, distinguish the human brain from those of other animals. These lobes govern cognitive and emotional processes of a higher order, processes related to one’s moral sense and one’s capacity for judgment and compassion. Patients on Prozac are sometimes so dulled that they resemble, in their indifference, people who have been lobotomized. Rudolf Hoehn-Saric, for instance, a researcher at Johns Hopkins, reported on a twenty-three-year-old man with obsessive-compulsive disorder who was put on a very high dose of Prozac: 100 milligrams, which is 20 milligrams higher than the highest FDA-approved dose. This patient, after taking the 100 milligrams daily for four months, developed what appeared to be frontal-lobe syndrome, displaying extreme apathy and indifference.

  For every example, however, there are always counterexamples. Some patients appreciate the dulling effect of Prozac and experience it not as a numbing force but as a welcome de-amplification of what was previously a chaotic and operatic existence. Ella Rose, an eighty-three-year-old woman who had been hospitalized eight times in her adult life for severe depression and OCD before going on Prozac, describes struggling each day with a weight in her limbs. “There was so much darkness,” she says, “so much difficulty. I couldn’t cry even though I longed for the release of tears. I worried about everything and had to compulsively check that the stove was off, off, off. I dragged myself through days. On Prozac, that weight and worry are gone. And in their place I have access to a full range of emotion, and I can cry, which is a gift to me. Depression and obsession clog up the pathways in my brain, so other normal emotions can’t come through. Prozac clears the mental plumbing.”

  After getting that initial prescription from Dr. Salzman, I myself took Prozac for seventeen years before its effect finally wore off and I had to switch to another serotonin booster, Effexor, which acts on norepinephrine as well and so is called an SNRI—serotonin-norepinephrine reuptake inhibitor. Prior to my taking Prozac, both before and while I was on imipramine, my emotions were wild and I was whipped between states of utter despair, whirling anxiety, and unstable ecstasy that allowed me to pull all-nighters writing lengthy tomes that later, in the sober light of another day, lacked what I felt at the time of composition had been a pure poetic essence. I was also a revolving-door mental patient, in and out of the hospital, admitted and discharged five times between the ages of thirteen and twenty-four, with not much hope for a full future. I cut my arms compulsively and many days did not make it beyond the bed. As with Ann Bolo, the world for me felt impossible to negotiate. I would lie beneath unwashed blankets and think, I have to take a shower, but I utterly lacked the ability to initiate the task. Even the effort of setting my feet on the floor seemed insuperable, a problem of deep and complex dimensions.

  Prozac turned my life around and did it fast, one two. It was as if my world had been
washed with Windex and everything had an elfin sparkle at its edges. Delightful, joyful, joyous. With my psychiatric symptoms removed, there was suddenly room in my mind for a whole range of new feelings, and thus Prozac did not blunt me at all. Like Ella Rose, I wept easily and copiously and enjoyed this simple feeling of sadness, which had a sort of purity. During my early years on the drug, I was alternately sad, happy, angry, excited, curious, and confused, which is another way of saying I was getting my bearings as a healthy person, learning to let go of sickness and all its symptoms. These were heady, incredible times. Ice cream tasted purer. Lychees were so aromatic. There was something sweet in the sadness I was now able to experience, so different from the deadness of depression.

  I did fret, however, over my sudden inability to write. It was as if Prozac had dried up the well from which my deepest dreams and images sprang. For the first eighteen months on the drug I didn’t set pen to paper, but gradually, eventually, I decided to try a short story or two, a brief essay about an animal I had loved long ago. I found that while words came more slowly to me on the drug, and that Prozac prevented the high I had sometimes felt when composing drug-free, or on imipramine, I could indeed still write, although to this day I sometimes worry that I have forever lost some wattage to the pill.

  Sex Addicts

  Because Prozac dampens the sex drive, psychiatrists often use it to treat compulsive masturbators and others with heightened libido or sexual-addiction disorders that leave their lives in shreds. Martin Kafka, a psychiatrist at McLean Hospital in Belmont, Massachusetts, the same place I go for my monthly med checks, has an entire practice comprising men who are addicted to sex. These are largely married men who nevertheless seek out prostitutes and pornography, not once a day, not twice a day, but twenty or thirty times in a twenty-four-hour period, men haunted and ravaged by their own internal fires, men eaten alive by uncontrollable desire, men whose brains are likely damp with dopamine coursing down dendrites and being sucked up by axons in a never-ending obsessive circuit. Kafka treats these men with what you could call a chemical castration. High doses of Prozac make it difficult, if not impossible, for his patients to maintain an erection, never mind to bed multiple partners. Kafka is not the only psychopharmacologist who uses Prozac and its chemical cousins in this manner. The literature is rife with cases of excessive masturbation, fetishes, compulsive staring at crotches, ungovernable promiscuity, all trained and tamed by serotonin-boosting drugs. Kafka has seen these drugs turn men around, has seen his patients go from the far fringes of fantasy, pornography, and prostitution to surprisingly conventional existences, picket fence and all.

  Sex addicts for whom Prozac allows a normal life, most of whom are men, generally tend to be grateful for the gate the drug has placed in front of them. With their genitals mostly offline, they’re permitted to remain in their marriages. And even if these marriages are all but sexless, most sex addicts report being happy to accept erectile dysfunction in exchange for freedom from a relentless and driving need—so happy that few appear to reflect on the disturbing fact that they are now dependent on a drug that could be causing damage to the dopamine systems in their brains, damage that may make them more vulnerable to developing Parkinson’s disease later in life. It’s a risk they’re willing to live with.

  Unable to Fall in Love

  The vast majority of patients who take Prozac, however, are not men but women. According to data compiled by the Centers for Disease Control and Prevention, researchers estimate that in this country women are two and a half times more likely to take an antidepressant than men, and that fully 23 percent of women aged forty to fifty-nine are on an antidepressant. Thus, if sexual dysfunction affects up to 75 percent of them, we have a staggering number of American women, maybe as many as 15 million or more, walking around without libido or desire or the ability to orgasm, women who used to notice a nick in the chin or a certain smell of sweat, but who are now numb to all that in their happy, cocooned state.

  Anthropologist Helen Fisher, a researcher at the Kinsey Institute, and psychiatrist J. Anderson Thomson Jr., a trustee for the Richard Dawkins Foundation for Reason and Science, have asked a disturbing question and put forth a disturbing theory relating to Prozac’s dulling effect on female libido. What might it mean to have millions of women indifferent to sex? Fisher and Thomson worry that as generic forms of the serotonin boosters become available and cheap, only more women will have their sexuality dulled. After all, it has been well established, they write, that these medications can be responsible for “emotional blunting” and dysfunction in sexual desire, arousal, and performance in as many as three of every four patients. The human brain has essentially three sexual systems within it, one for courtship, one for mating, and one for reproduction and parenting. A healthy sex drive motivates a woman to seek out a range of partners even as her capability for romantic attraction prunes the partners back, helping her, according to Fisher and Thomson, in “conserving mating time and metabolic energy” by ultimately focusing on one person. The capacity for attachment, in turn, allows human beings to stay in a relationship ideally long enough to complete parenting duties.

  But Prozac and other serotonin boosters, Fisher and Thomson suggest, put a deep dent in the neural substrates that underlie romantic attraction, courtship, mating, and maybe even parenting. Studies using fMRI scanning of the brain show that romantic attraction and courtship are mediated via the dopamine system, the very system that Prozac in particular and the serotonin boosters in general suppress. “Hence,” write Fisher and Thomson, “serotonin-enhancing antidepressants can jeopardize one’s ability to fall in love.” They further hypothesize that because of Prozac’s widespread effect on the sex drive, the medication can also interfere with mate assessment, mate choice, and partner attachment.

  The reason is that while the male orgasm serves an obvious evolutionary role, the female orgasm, a more subtle phenomenon, also has a critical purpose in the evolution of our species. Not only does the female orgasm aid in sperm retention, but also it allows women to better differentiate between self-centered and compassionate partners. A man who cannot bring his partner to orgasm, for instance, likely lacks the necessary sensitivity and skill that promote female sexual pleasure. But a woman whose libido has been suppressed by Prozac loses the ability to discriminate between partners who can take the time and effort to please her and those who can’t or won’t. In some sense, then, the drug wipes out a critical monitoring device built into the female brain. Stoked on Prozac, women are at higher risk for choosing men who lack the capacity to care about their needs and wants, and may therefore fall into a relationship that is stale—or, worse, incompatible—from the start, a relationship that, furthermore, puts her future progeny at risk because the bond with her mate lacks the stability and solidity it will need to make it through the early years of parenting.

  Studies also show that women will be more orgasmic with men who have symmetrical body features, given that outward symmetry is a sign of inward sanguinity and health. Therefore an orgasmic woman will be naturally drawn to male symmetry while a woman who has a suppressed libido has a sort of sexual blindness. With her dopamine system blunted and her serotonin surging, such a woman is cut off from the critical currents that suggest a “good catch.” If Fisher and Thomson are correct, then currently, worldwide, there are millions and millions of women whose sexual detection systems are askew, women who are more vulnerable to making poor choices, which will then have a damaging domino effect that can go on for generations, as unhappy unions lead, perhaps, to divorce, and children bear the brunt of the familial collapse.

  Beyond that, sexual relationships are likely not the only type of bonding that Prozac affects. Or, to put it another way, almost all adult relationships have a sexual/erotic component of some kind, albeit usually an unconscious one. This component adds energy and gives synergy to twosomes. Studies show that touch stimulates the release, in our bodies and brains, of oxytocin, sometimes called “the love horm
one,” which helps us bond with everything from pets to cousins to husbands and wives. Oxytocin is tightly tied to the dopamine system, which Prozac suppresses, so there’s a reasonable chance that, fueled by a serotonin booster, we will deprive ourselves of the benefits of this important bonding hormone as well.

  One could claim that Fisher and Thomson’s evolutionary theory is hogwash—that sperm do just fine whether or not the female has an orgasm, and that symmetrical facial features are an entirely subjective phenomenon and do not point toward a robust mate with a complementary immune system. But even if Fisher and Thomson were entirely wrong, they would still, in essence, be right. We have, by now, enough anecdotal reports to be able to say with certainty that in a large number of users, Prozac and its chemical cousins create a more blasé attitude toward the slings and arrows of life. The drug allows you to glide over serrated surfaces, unaware that you are tearing your tender soles. Evolutionary theory aside, we know that Prozac makes people feel good enough to tolerate compromised or even outright dysfunctional relationships that, in an unmedicated state, one would simply be unable to adapt to. There are, of course, far-reaching political ramifications to this, but even on a very micro scale it looks creepy. A wife adjusting to her husband’s serial affairs. A husband adjusting to his wife’s compulsive spending. Children adjusting to poor teachers. The high gloss and shiny polish that Prozac puts on the surface of life is not a warning or a maybe. For millions of people it is the total truth.

  By 1993, five years after Prozac was released for public consumption, it was the top-selling antidepressant in the world, with doctors writing millions of prescriptions for the pill per year. The release of Prozac dovetailed with the rise of managed care, so it was not at all unusual for a patient to see a psychopharmacologist once, maybe twice, and, like Ann Bolo, walk away with a year’s worth of prescriptions for the drug and no substantial follow-up in place. By all appearances Lilly had hit a home run with its new drug. The public clamor for Prozac that followed in the wake of the Newsweek cover feature and the myriad articles written about it in the mainstream press resulted in the company’s grossing well over $1 billion in sales of Prozac in 1993. The drug was even sold on the street, where it was crushed up and snorted for what some dubiously claimed was an immediate high.