The Creation of the Prozac Myth

Published at the Guardian.uk, Feb. 27, 2008

In the 20 years since its launch, 40m people worldwide have taken the so-called wonder drug - but research revealed this week shows that Prozac, and similar antidepressants, are no more effective than a sugar pill. So how was the myth created? Psychoanalyst Darian Leader traces the irrepressible rise of the multibillion dollar depression industry, while others explore the clinical and cultural impact of Prozac, its perceived personal benefits - and sometimes terrible costs

Has the depression bubble finally burst? Yesterday's headlines about the inefficacy of Prozac and other bestselling antidepressants must have been an unpleasant shock, not only to the drug manufacturers, but also to the millions of people in the UK taking these drugs. The new research, published in the Public Library of Science Journal, found that a placebo was just as effective as the drugs - excepting in some cases of severe depression, where it was not the drugs that did well, but the placebos that did worse.

What will the impact of this new research be? Is it a case of recognizing that the Prozac emperor never had any clothes? Or, on the contrary, of acknowledging the power of placebo and finding new ways of working with it?

For many researchers, the PLoS findings actually reveal nothing new. Several earlier studies comparing placebo with antidepressant drugs had found that there was not much difference, yet these results had little media uptake. The new paper owes its coverage partly to the fact that it includes data from clinical trials that the manufacturers chose not to broadcast. As criticism of the industry's withholding of such results mounted, drug companies were forced to make unflattering results public.

It is only very recently that this has become a legal obligation. In the heyday of antidepressant PR, only about 10% of results about how the drugs affected quality of life were published. More than two-thirds of studies today are industry funded, and such research is four times as likely to find in favour of the drugs than independent inquiry. It is hardly surprising, then, that research has tended to give a positive spin to antidepressants.

The new negative results might seem to promise a change of direction. But they may just be the other side of the industry coin. What remains unchallenged is the diagnosis of depression itself. GPs diagnose it every minute of the day, celebrities reveal they suffer from it and soap opera characters wrestle with it. Yet 40 years ago depression was hardly anywhere. A tiny percentage of the population were deemed to suffer from it. So what happened?

These developments actually followed a surprising course. The story of depression cannot be dissociated from the story of its supposed remedies. And these, like nearly all psychotropic drugs, were not the result of targeted research, but of chance association. The first drugs had in fact been used as antihistamines, yet they seemed to have effects on mood, energy and anxiety.

Although epidemiological studies had found high levels of nervous conditions in the community before these drugs were marketed, this had not been diagnosed as depression. With the marketing of the drugs, this nervous substrata was now labelled as a depression which had gone unrecognised and untreated. Yet this knowledge was not seized on and marketed until the drugs market made this happen in the late 70s.

Where depression had been rated at 50 per million in the early 60s, by the 90s this had jumped to 100,000. These remarkable changes coincided with the crisis in the market for minor tranquilisers such as Librium and Valium, prescribed for anxiety. As these widely used drugs were found to be highly addictive, it looked as if a substantial market was about to collapse. Hundreds of thousands of people took these drugs and the economic gains were enormous. Anxiety had to be remarketed and new agents found to respond to it. And this is where depression started to really take off as a diagnosis. First of all, however, it had to be constructed as a discrete, well-defined clinical entity.

Why couldn't the drugs companies have simply offered their products as tonics or general mood enhancers? After the thalidomide scandal in the early 60s, tough new standards were set in place and drugs had to specify their active ingredients, the outcomes sought and the delivery period for attaining them. This meant a new kind of surface precision. Drugs would have to pass expensive trials proving they were more effective than placebo and do better than other drugs used for this same group of target patients. These new standards brought with them a new technology to evaluate. Randomised controlled trials became the norm, together with a silver bullet model of illness according to which each specific disorder would have a specific cause and a specific treatment.

These changes in the landscape of prescription medicines framed the market for the antidepressants. Since the new diagnosis needed to be publicised, drug companies paid for adverts in medical journals, glossy pullout supplements, conferences and clinical studies to show the prevalence of depression. When Frank Ayd wrote his book Recognising the Depressed Patient, the pharmaceuticals giant Merck bought 50,000 copies and distributed them to GPs. The book argued that depression was going undetected and untreated in the community. This dissemination of knowledge coincided nicely with their marketing of a new treatment for depression in the form of amitriptyline.

The later generation of SSRI drugs had an even more exponential success: by the late 90s Prozac was a household word, with millions of prescriptions and a whole cult of novels, films and memoirs based around it. In 2005, traces of Prozac were even found to be present in British tap water.

This process of marketing depression helped create the clinical category itself. If the new drugs affected mood, appetite and sleep patterns, then depression consisted of a problem with mood, appetite and sleep patterns. A subtle shift in the defining symptoms of depression took place over the years, so that the category itself became taken for granted. Lost here was the simple idea that there is a difference between surface symptoms (insomnia, loss of appetite, feeling low) and underlying causes, which may be different from case to case. The creation of the antidepressant market effectively disallowed this once crucial distinction.

What would happen, after all, if surface symptoms were separated from underlying causes? How would the clinician make a prescription? What would be targeted? Pretty soon, the absurdity of the idea of a drug curing underlying causes would become clear. How could a drug cure the experience of having lost a loved one, for example? It might numb the pain, but it couldn't really do much more than that.

According to the new research, what it can do can also be done by placebo. Would this herald a new era of placebo-based medicine? The answer is complicated since all medicine involves placebo. Placebo means that our belief systems are mobilised and these have an effect on how we feel. The popular view here is that we only think we feel better, yet more than 100 years of research shows that beliefs can have very real effects in our bodies. A doctor's words, a diagnosis, a white gown, the size of a pill - all of these can have effects on our physical health. What matters will be our unconscious beliefs and expectations about the medical encounter.

This means that placebo and "real" treatments can't be so neatly opposed to each other. The alternative pathway is to explore a person's beliefs and unconscious mental life, and this can only take place thro ugh long-term listening and dialogue. The negative findings about antidepressants are timely here, coinciding nicely with the government's initiative to provide talking therapies to millions of depressed and anxious people. Companies are already bidding for the cash, and the Department of Health has pledged to create a "workforce" of new therapists.

But will this really address the problem? If antidepressant drugs are losing out, the therapies that the government favours - mostly cognitive-behavioural - are based on the very same principles as the drugs. They target surface symptoms, they must deliver set outcomes and they must do this in a set period of time. In fact, these are exactly the same criteria as the drugs but without the drugs.

Isn't this in essence a resurgence of the mental hygiene movement that many thought a relic of the early 20th-century? Cognitive therapies are being tailored to replace drugs, and treatment will become more and more mechanised, ignoring the real dynamics of human interaction. Symptoms will be seen as mistakes to be corrected rather then legitimate expressions of unconscious conflicts or desires. Shouldn't the new results encourage us to treat quick-fix solutions with scepticism? And to listen carefully to what lies beneath the surface depressions of each individual sufferer?

· Darian Leader is the author of The New Black: Mourning, Melancholia and Depression, published by Hamish Hamilton.

The cultural critic: Stephanie Merritt
'Prozac will surely survive as a metaphor for the pursuit of instant chemical happiness'

Last May, a front-page headline in the Times gloomily declared that Britain had become a "Prozac nation". This was 13 years after Elizabeth Wurtzel's bestselling memoir of the same name had expressed the same fear about America, but no mention was made of Wurtzel's book in the piece. The phrase now stands alone; "Prozac" has entered our collective consciousness not merely as a brand but as a concept, a shorthand for instant, artificial happiness - medication as a contemporary lifestyle choice.

Wurtzel's book was instrumental in planting the idea of Prozac as an iconic, Generation X accessory. The jacket photograph offered the author in rock-chick pose, brilliant, sexy and sad-eyed, almost single-handedly changing the perception of what it meant to take psychiatric medication. The old-style tricyclic antidepressants made you fat and slow, blunting your responses; the stigma of real mental illness attached to them. But not Prozac.

The name was developed for the pharmaceutical company Eli Lilly by the Interbrand agency; "Prozac" suggested positive and professional and zappy, and conveyed the idea that taking antidepressants did not have to mean you were actually mentally ill. Instead, you could be young and troubled by the world, a bit arty, stressed out by your high-achieving lifestyle, in need of a quick pick-me-up, an aspirin for an existential hangover. Prozac was eagerly grasped as the embodiment of a dream, the idea that an antidote to the pain of modern living could really exist in one simple pill.

We wanted to believe in it. As the Magnetic Fields' frontman Stephin Merritt writes sardonically in his song I Don't Want to Get Over You: "I guess I should take Prozac, right,/ and just smile all night, at somebody new?" The line reflects a fundamental misconception about Prozac, held by many people who have never taken it - that it functions much like ecstasy, bestowing an instant fuzzy, smiley glow. In reality, Prozac, in common with other SSRI drugs, usually takes about six weeks to take effect, during which time you often feel much worse, but the mythology has proved more poetic than the reality. A similar misunderstanding occurs in Vanilla Ice's 1998 song Prozac, in which he claimed "We gets crazy like Prozac/Hype enough to start a party and illy have a heart attack", which is not a frequent effect of Prozac (unless you have undiagnosed bipolar disorder, in which case SSRI antidepressants can precipitate a manic episode).

In 1997, the young Spanish writer Lucía Etxebarriá published her first novel, Amor, Curiosidad, Prozac Y Dudas (Love, Curiosity, Prozac and Doubts), the story of three sisters trying to make sense of what it means to be a woman in modern Spain. The book was regarded as one of the key Generation X Spanish novels, exploring issues not of mental illness but of the more generalised anxieties of contemporary life and female identity.

Jonathan Franzen does something similar in his 2001 bestseller The Corrections, in which one of the characters is persuaded to take medication that will rid her of the sensations of guilt and shame. The drug is fictional, but the debate is clearly informed by the author's own description elsewhere of concerns about whether or not to take Prozac during a period of depression (in the end, he decided against it). In an interview with the Guardian at the time he said, "Alleviating suffering is very good, but it comes at the cost of what I would call a narrative understanding of one's life. You don't need to have a story any more. Your story becomes: the chemicals in my brain were bad; I fixed those chemicals."

Even before the present allegations that Prozac and its SSRI cousins do not really work, people had grown troubled by this idea that medication dampens our ability to connect with the world and to experience the full spectrum of human emotion. Recent self-help books have invoked Prozac to embody our misguided over-reliance on medication; Potatoes Not Prozac, by Kathleen Desmaisons, advocates nutrition over drugs, while Plato Not Prozac, by Lou Marinoff, urges philosophy instead of pharmaceuticals to soothe troubled minds.

But in a culture where the dividing line between the confessional memoir and the novel grows increasingly blurred, the obsession with individual consciousness will remain a prominent concern for writers - and Prozac will surely survive as a metaphor for the pursuit of instant chemical happiness, even if that ideal turns out to have been a giant collective delusion.

The sceptical psychiatrist: David Healy
'Are clinicians trained to read the evidence? Sadly not'

Some people will be shocked to discover that Prozac has been prescribed so widely for decades when, in fact, it barely works. However, the real story is even worse. First, the findings are not new, and it is not only the Prozac group of antidepressants that we should be concerned about; second, the findings point to a general medical inability to understand evidence; and, finally, they reveal the dark side of company marketing, and the role of regulators.

In 2006 - in a review that was much larger and more far-reaching than the recent one undertaken into Prozac - the US Food and Drug Administration reviewed all antidepressant trials, with data from 100,000 patients. The FDA reported that while five out of 10 people appeared to respond to the pills, four out of 10 responded to the placebo.

In a clinical trial, a drug is said to "work" when differences between the group taking it and the control group are statistically significant. In sufficiently large trials even a small difference may be statistically significant. As a result of this, drugs that are sedating or tranquillising can be deemed to "work for depression". Provided the drug can be shown to beat a placebo in two trials, the regulators are prepared to license it - even if it fails in the other 98 trials out of 100. The regulators acknowledge that what they do is take these hints that the drugs "might" work as grounds to let companies market them as effective treatments.

And once regulators have approved such drugs, companies market them by selectively publishing from the trials undertaken, in articles that are little more than marketing copy appearing under the apparent authorship of the biggest names in the field and in the most distinguished journals.

But once marketed, surely clinicians are trained to read the evidence rather than just reach for their prescription pad? Sadly not. If the four out of five responding to the placebo are stripped out of the apparent drug response, the figures show only one out of 10 people have a true response to the antidepressant. Meanwhile, we know that the natural history of depression means that many will improve within weeks whether treated or not. It is also thought that sensible advice on matters of diet, lifestyle and alcohol intake, as well as basic problem-solving on work and relationship issues, may make a difference. And it is suspected that our perceptions that we are being cared for by a medical expert may make a difference, an effect that may be enhanced by being given a substance we think will restore some chemical balance to normal - even if that imbalance is mythical.

Put this way it becomes clear that if clinicians are to follow the evidence, they should have a greater resort to judicious waiting. As Philippe Pinel put it 200 years ago: "It is an art of no little importance to administer medicines properly: but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them."

While many clinicians appreciate this point in the abstract, few practise medicine in this way or caution us that an apparent response to treatment may not stem from the drug. This is not an argument for cognitive behavioural therapy over pills. In fact, the evidence for CBT is similar to that for pills - the greater part of the response comes from placebo factors.

The fact that the same arguments are made to "sell" both CBT and pills show that the problems lie deeper. Controlled trials mandate interventions. And when the trials are conducted within a framework in which "No" is the one thing that cannot be marketed, we risk being separated from the traditional art of medicine. What we gain in "facts", we lose in wisdom.

· David Healy is Professor of Psychiatry at Cardiff University and the author of Let Them Eat Prozac (New York University Press, 2004).

The reluctant Prozac user: Steven Stone
'I worry I'll never come off - but I'll take that risk'

It was the constant click-clacking in my brain that I couldn't bear - like a metronome swinging from side to side in my frontal lobe. Often the metronome would be obsessive thoughts or fears (about anything - being thick, being hated, being ugly, being found out), sometimes it would just be a vacant clicking. It got so bad that I couldn't think of anything else. People would ask me the time and I wouldn't be able to tell them (that in itself became an obsessive fear). I was a subeditor for a newspaper, and I'd have to take articles to the toilet to try to make sense of them because the click-clacking wouldn't allow information to filter through.

I was terrified of being exposed. People would talk to me, and I'd get a "face sticker" - my face would petrify, unable to respond to what I was being told. It makes me sound like a right miserable bastard, but I wasn't and I'm not - when I'm being objective I know that I'm quite funny and popular and bright in my own way. But that's the thing about my kind of depression - you lose objectivity.

I've been depressed since my mid-teens. What it meant was that although there are loads of things I love in life - football, film, books, friends - there's nothing I truly look forward to. I remember going away to Greece with three close friends and hoping it would rain because at least that would give me an excuse to feel miserable. What I longed for more than anything was that ability to feel happy because the sun was shining or I was with people I loved or things were going well, to feel shit because shit was happening.

At around the same time I went on my first antidepressant. It made me want to sleep all the time. It was a form of human cosh. If this was living it wasn't worth it.

Depression ran in my family. My father had it bad. What I didn't know until recently was that his dad, whom he never spoke about, spent his final years in a mental hospital.

Things reached their nadir about a year after a very close friend killed herself. The metronome felt as if it would splinter my skull, I was still thinking about my friend a lot, and one day somebody drove me over the edge at work. I cracked up.

The next day I was walking in the middle of the road, crying my eyes out, half hoping cars would hit me. I somehow got myself to the doctor, who sent me straight to a psychiatric hospital, where they told me they would not make me stay there if I agreed to take an antidepressant - Prozac. Reluctantly, I agreed. The first few weeks were horrible - I was still weak from cracking up, the Prozac made me feel sick, and it made it hard to ejaculate (not that I cared much about that at the time).

But after a few weeks I realised the symptoms had eased, and the click-clacking metronome was gone. I could think straighter than in decades. It was such a relief. I had no idea that life could be so easy. It wasn't that I'd morphed into one of those happy shiny people REM sang about, but I was in a fit state to operate my life. I still had plenty of fears and anxieties, but they were incomparable.

Most people come off Prozac after a year or two. I've tried, and ended up being a tear-stained wreck. So for 12 years, with the odd unsuccessful break, I've stayed on the drug and throughout that time I've supplemented it with natural Prozac - running, football, fresh air. I have read countless stories about Prozac-takers being more likely to kill themselves and kill others, and they worry me a little. And now I'm reading that they don't work anyway unless you've got severe depression, which soon gets reduced in the headline to "Prozac doesn't work". Perhaps the truth is that Prozac doesn't work for people who are not clinically depressed (why should it?) and lots of people who are not clinically depressed are prescribed it by doctors. And I'm sure Prozac doesn't work for all people who are clinically depressed.

As for me, I do worry sometimes that I might be addicted by now; that I'll never come off it. But I'm prepared to take that risk. Who cares if it's allowed me to live my life?

· Steven Stone is a pseudonym. 

The bereaved mother: Linda Hurcombe
My teenage daughter was prescribed Prozac; 63 days later, she hanged herself

When I read the news yesterday over the cornflakes, my first response was anger. I find it incredibly frustrating that it has taken 20 years to reach the stage where the emperor's new clothes are only now being seen for what they are.

Ten years ago my irrepressible teenage daughter Caitlin returned from holiday with relatives in the US, where prescription drugs are widely advertised; she saw an ad for an antidepressant drug called Prozac and wanted to try it. She went to our local GP and it took her eight minutes to get the prescription. Sixty-three days later, during which time she descended into unprecedented chaos, including neural twitches, violent nightmares and self-harm, she hanged herself. Since then, I have become something of an expert on the effects of these drugs.

It took 20 years for the adverse effects of Valium to emerge. Maybe it takes 20 years in our world of global drug pushing for the truth to emerge. Here's a ballpark sketch of the past 20 years since Prozac and its younger sisters came on the market.

Stage one: a miracle drug is discovered that chases those blues away.

Stage two: problems with "miracle drug" in clinical trials, suppressed at the time, begin to emerge. Court cases are launched, then settled out of court by drug companies.

Stage three: systematic emergence of nightmare stories associated with the drugs, with antidepressants being linked to a specific condition called akathisia (a feeling of intolerable restlessness and agitation, described by patients as feeling that they are "jumping out of" their skin), to violence, suicide and more sensationally to school shootings.

And now it seems we're at stage four: reliable research reveals that the drug mainly doesn't work any better than a placebo.

What a wonderful word, "placebo" - to please, soothe, gratify. Like friendship, counselling, community, diet, exercise, breathing techniques, even laughter. But while Prozac is no better than a placebo, it can be much worse. A placebo has no adverse side-effects.

· Linda Hurcombe's daughter Caitlin died in 1998. She is the author of Depression: healing emotional distress (Sheldon Press). 

The GP: Steven Field
'We want to help, but sometimes there's a waiting list of years for talking therapies'

GPs see many patients with depression, and they often present at quite a late stage, particularly men. Sometimes the patient will ask for antidepressants because they don't know what the other options are. Other times, the GP wants to help, but doesn't have access to talking therapies, because availability varies greatly across the country. We are delighted that the government has committed to giving more money to talking therapies. But in some cases there's a waiting list of many years, so what do we as GPs do?

Medical training emphasises carrying out a proper assessment of the patient: looking at their mental health, their social situation, their work environment and their physical condition. We look at talking therapies as well as physical ways of managing illness, such as exercise. These are proven to be as, if not more, effective than medication.

But, as the report says, for severe illness, antidepressants are useful. Patients find it very difficult to assess their own level of depression, so we wouldn't want people to come off their medication. Instead, I would encourage them, when they next see their GP, to talk through their illness and discuss what treatment is most appropriate.

· Professor Steven Field is chairman of the Royal College of GPs and a practising GP in central Birmingham. 

The former inpatient: Clare Allan
'I've shuffled about like an overweight penguin. Only Prozac made me feel better'

I am always slightly suspicious when a psychiatric story makes the headlines. Generally speaking, mental health is not a front-page issue. It makes people uncomfortable, precisely because the lines dividing "mentally ill" from "mentally healthy" are frustratingly indistinct. Mental illness doesn't show up on the scanner; a blood test has yet to be devised and until some genius comes up with one (wouldn't that make the headlines!), a diagnosis remains little more than a doctor's opinion.

I am certainly no great defender of medication and I wouldn't be at all surprised to learn that antidepressants are sometimes prescribed inappropriately. But I have a personal stake in this story, having taken medication ever since I first broke down about 12 years ago. I've tried a range of drugs from antipsychotics to antidepressants, mood stabilisers and God only knows what else. I shuffled about like an overweight, drugged-up penguin. For me, Prozac was the only drug that actually made me feel better, as opposed to just numbing me senseless. I've been on it for 10 years.

None of this lends itself to a simple conclusion. Depression isn't something you can measure with a ruler. If you have ever completed a questionnaire designed to assess your mental health, you'll know all too well the unbridgeable gap between your own individual experience and the multiple-choice answers on the form. Depression is not precise and tangible. Treatment needs to be tailored not just to diagnoses but to the individuals behind them. And this individual, for what it's worth, intends to keep taking her tablets.

· Clare Allan is the author Poppy Shakespeare. 

The ex-user: Hannah Borno
'I loathe the emotional numbness Prozac gave me'

I was 27 when I first took Prozac. Trying to finish my Phd in digital archaeology, I'd lie in bed gazing out of the window at the sky, weeping constantly. My very first thought in the morning would be: "I hate myself."

I was plagued by images of jumping out of windows and landing on hard pavements. Where these images came from I don't know, but I went to the doctor, enjoyed her sympathy, and ended up with a packet of fluoxetine [the generic name for Prozac].

Taking a white and green pill every morning became a comforting ritual and, bizarrely, made me feel somehow taken care of. It was the first thoughtful thing I had done for myself for months. After a fortnight my weeping simply stopped, I began to experience tiny head-rushes and felt lighter, as if I was floating instead of walking. I felt "cushioned" - both mentally and physically. I didn't feel happy, but I didn't feel sad either. The suicidal thoughts faded away.

But so too did all empathy - I became apathetic and politically unengaged. I couldn't feel my own pain, but I couldn't feel the pain of others' either. This calm didn't extend to the times when I was drinking, when I became noticeably more energised, unpredictable and sometimes downright unpleasant. Eventually, I decided to stop taking them completely.

After about a week I started to experience withdrawal symptoms. I became alarmingly emotionally numb and felt depersonalised - like a robot. Whereas when I was depressed I couldn't get out of bed, now I could function but my heart and mind were empty. I couldn't react to people or situations spontaneously, and I couldn't laugh or cry. I was also experiencing strong heart palpitations, and painful pins and needles in my arms and legs.

Three months later I began to defrost. Never before have I been so happy to weep. I started seeing a cognitive therapist, and read Feeling Good by David Burns, a cognitive behavioural therapist. I can now head off depressive episodes by spotting a rise in the frequency of negative thoughts and making a conscious effort to combat them.

I'd never take Prozac again because I loathe the emotional numbness it gave me. I also found the physical withdrawal distressing. I did stop weeping when I first started taking it,and consciously taking a pill each morning is a powerful statement of intent which I'm sure could produce a significant placebo effect. But for me antidepressants, placebo or no, are surely only ever short-term solutions for depression.

The novelist: Elizabeth Wurtzel
'I didn't set out to become synonymous with Prozac'

When my book first came out, I wanted to call it I Hate Myself and I Want to Die'. But my publisher chose Prozac Nation, and it turned out to reflect what became a phenomenon. It wasn't that way when I first took Prozac. I do find the culture of medication amazing. It's not a taboo any more: you can meet someone walking your dog and they'll tell you they're on Prozac.

It wasn't my intention to become synonymous with Prozac; it's very strange, but what can I do? Really, it's a story of my depression and recovery. People who have read the book talk to me about depression, but people who haven't talk to me about pills, because that's what's on the cover. I did take Prozac, and I'm still on medication, but I don't think that medication can work without therapy. In an ideal world, I wouldn't be on anything, but if I could chose, I'd rather just be in therapy.

· Elizabeth Wurtzel is author of Prozac Nation. 

The psychotherapist: Derek Draper
'Providing human support is harder and more expensive'

Knowing that the effectiveness of SSRI's such as Prozac has been overstated is only one part of the equation. We need to make therapy as readily available as these drugs have been. Only one in 40 people with depression and anxiety now get effective "talking treatment".

Yet therapy works. The latest large-scale study showed that it is effective for around 70% of people. A landmark study by US Which? magazine indicated that nine out of 10 people found their therapy helpful. The good news is that the government has committed hundreds of millions of pounds to expanding such provision. There is, as ever, devil in the detail. Some believe the only therapy that should be provided is cognitive behavioural therapy (CBT) whereas many therapists - and the leading mental health charities - want to see a variety of therapies available.

We do need to retain a role for medication in certain cases, however. I believe they played an important role in my own recovery from depression a decade ago - alongside therapy. But therapists have always believed that depression is more than simply a chemical imbalance that can be "reset" with pills. It is about distorted thoughts, feelings and beliefs all of which can be effectively explored and challenged with the help of another, skilled human being.

Providing such support will always be harder and more expensive. But now perhaps we can put more of our efforts into providing - and engaging with - such human help.

· Derek Draper is a psychotherapist with diy-therapy.com

The defiant user: Cath Kennedy
'What are you saying? I have imagined the changes to my life in the past 12 years?'

The claim that Prozac is nothing more than a placebo is an insult to the millions of people (and I am one) whose lives have been transformed by taking it.

I began taking Prozac 12 years ago, at 30, after the breakup of a relationship. I couldn't stop crying and I couldn't work. I made no mention of the fact that I had also been heavily bulimic for 15 years. I'd accepted that the eating disorder was part of my make up and was going to be with me for life.

After a week I felt more positive. But I soon noticed other effects. My eating regulated. After about a month, I realised I hadn't vomited for weeks. Only then did I check the small print on the Prozac packet and find that it is also prescribed for people with bulimia. And it didn't end there. One of my other problems was that in certain situations, I found myself cripplingly shy. This, too, gradually lessened; again, no one had suggested to me this might be a side-effect of the drug.

Over the years I have come off Prozac for short periods. Early on, I became bulimic again when off it. Even now, when I come off Prozac, I notice I am less ready with small talk, more paranoid, more prone to unhappiness.

Now, these reports suggest that I have imagined the changes to my life in the past 12 years. I have somehow altered my personality and my habits, not with the help of this pill. I believe I have a simple chemical imbalance that has been fixed. It's infuriating to hear it suggested that the extremely beneficial effects I have experienced have merely been a "placebo" effect.

Prozac works. It changed me from a woman whose insecurity had manifested itself in a crippling eating disorder and shyness, into someone who was able to interact without problems. Lucky you if you can do all this without help.