My first experience with Prozac involved a woman I worked with
only around issues of medication. A psychologist with whom I co1Iaborate had called to say she was treating a patient who had accomplished remarkable things in adult life despite an especially grim childhood; now, in her early thirties, the patient had become clinically
depressed. Would I see her in consultation? My colleague summarized the woman’s history, and I learned more when Tess arrived at my office.
Tess was the eldest of ten chi1dren born to a passive mother and
an alcoholic father in the poorest public-housing project in our city. She was abused in childhood in the concrete physical and sexual senses which everyone understands as abuse. When Tess was twelve, her father died, and her mother entered a clinical depression from which she had never recovered. Tess-one of those inexplicably resilient children who flourish without any apparent source of sustenance took over the family. She managed to remain in school herself and in time to steer all nine siblings into stable jobs and marriages.
Her own marriage was less successful. At seventeen, she married an older man, in part to provide a base outside the projects for her
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younger brothers and sisters, whom she immediately took in. She never went to the movies alone with her husband; the children came along. The weight of the family was always on her shoulders. The husband was alcoholic, and abusive when drunk. Tess struggled to help him stop drinking, but to no avail. The marriage soon became loveless. It collapsed once the children- Tess's siblings-were grown and one of its central purposes bad disappeared.
Meanwhile, Tess had made a business career out of her skills at driving, inspiring, and nurturing others. She achieved a reputation as an administrator capable of turning around struggling companies by addressing issues of organization and employee morale, and she rose to a high level in a large corporation. She still cared for her mother, and she kept one foot in the projects, sitting on the school committee, working with the health c1inics, investing personal efforts in the lives of individuals who mostly would disappoint her. '
It is hard to overstate how remarkable I found the story of Tess’s success.
I had an image of her beginnings. The concrete apartment in which she cared for her younger brothers and sisters was recently destroyed with great fanfare on local television. Years earlier, my work as head of a hospital clinic had led me to visit that building. From the start, it must have been a vertical prison, a place where to survive at an could be counted as high ambition. To succeed as Tess had -- and without a stab1e family to guide or support her – was almost beyond imagining.
That her personal was unhappy should not have been surprising. Tess stumbled from one prolonged affair with an abusive married man to
another. As these degrading relationships ended, she
would suffer severe demoralization. The current episode had lasted months, and, despite a psychotherapy in which Tess willingly faced the difficult aspects of her life, she was now becoming less energetic and more unhappy. It was this condition I hoped to treat, in order to spare Tess the chronic and unremitting depression that had taken hold in her mother when she was Tess's age.
Though I had learned some of this story before my consultation with Tess, the woman, when I met her, surprised me. She was utterly charming. .
I have so far recounted Tess's history as if it were extraordinary, and it is. At the same time, people like Tess are familiar figures in a psychiatrist’s practice. Often it will be the most competent child
in a chaotic family who will come for help – the field even has a name
for people in Tess's role, “parental children,” and a good deal is written about them. Nor is it uncommon for psychiatric patients report having had a depressed mother or an absent father.
What I found unusual on meeting Tess was that the scars were so well hidden. Patients who have struggled, even successfully, through neglect and abuse can have an angry edge or a tone of agreessive sweetness. They may be seductive or provocative, rigid or overly compliant. A veneer of independence may belie a swamp of neediness. Not so with Tess.
She was a pleasure to be with, even depressed. I ran down the .
list of signs and symptoms, and she had them all: tears and sadness,
absence of hope, inability to experience pleasure, feelings of worthlessness, loss of sleep and appetite, guilty ruminations, poor memory and concentration. Were it not for her many obligations, she would have preferred to end her life. And yet I felt comfortable in her presence. Though she looked infinitely weary, something about Tess reassured me. She maintained a hard-to-place hint of vitality-a
glimmer of energy in the eyes, a sense of humor that was measured and not self-deprecating, a gracious mix of expectation of care and concern for the comfort of her listener.
It is said that depressed mothers' children, since they have to spend their formative years gauging mood states, develop a special sensitivity to small cues for emotion. In adult life, some maintain a compulsive need to please and are thought' to have a knack for behaving just as friends (or therapists) prefer, at whatever cost to themselves. Perhaps it was this hypertrophied awareness of others that I saw in Tess. But I did not think so, not entirely. I thought what I
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was seeing was a remarkable and engaging survivor, suffering from a particular scourge, depression.
I had expected to ask how Tess had she managed to do so well. But I found myself wondering how she had done so poorly.
Tess had indeed done poorly in her personal life. She considered herself unattractive to men and perhaps not even as interesting to women as she would have liked. For the past four years, her principal social contact bad been with a married man -Jim- who came and went as he pleased and finally rejected Tess in favor of his wife. Tess had stuck with Jim in part, she told me, because no other men approached her. She believed she lacked whatever spark excited men; worse, she gave off signals that kept men at a distance.
Had I been working with Tess in psychotherapy, we might have
begun to explore hypotheses regarding the source of her social fai1ure:
masochism grounded in low self-worth, the compulsion of those
abused early in life to seek out further abuse. Instead, I was relegated tp the surface, to what psychiatrists call the phenomena. I stored away for further consideration, the contrast between Tess’s charm and her social unhappiness. For the moment" my function was to treat my patient’s depression with medication.
I began with imipramine, the oldest of the available antidepressants and still the standard by which others are judged. Imipramine takes about a month to work, and at the end of a month Tess said she was substantially more comfortable. She was s1eeping and eating normally – in fact, she was gaining weight, probably as a side effect of the drug. "I am better," she told me. “I am myself again."
She did look less weary. And as we continued to meet, generally for fifteen minutes every month or two, all her overt symptoms remitted. Her memory and concentration improved. She regained the vital force and the willpower to go on with life. In short, Tess no longer met a doctor's criteria for depression. She even spread the
good word to one of her brothers, also depressed, and the brother began taking imipramine.
But I was not satisfied.
It was the mother’s illness that drove me forward. Tess had struggled too long forme to allow her, through any laxness ofmy own, to slide into the chronic depression that had engulfed her mother.
Depression is a relapsing and recurring illness. The key to treatment
is thoroughness. If a patient can put together a substantial period of doing perfectly well -five months, some experts say; six or even twelve, say others -the odds are good sustained remission. But to limp along just somewhat improved, “better but not well.” Is dangerous. The partly recovered patient wilI1ikeIy relapse as soon as you stop the therapy, as soon as you taper the drug. And the longer someone remains depressed, the more 1ikely it is that depression will continue or return.
Tess said she was well, and she was free of the signs and symptoms
of depression. But doctors are trained to doubt the report of the too stoical patient, the patient so willing to bear pain she may unwittingly
conceal illness. And, beyond signs and symptoms, the recognized . abnormalities associated with a given syndrome, doctors occasionally consider what the neurologists call “soft signs”, normal findings that,
in the right context, make the clinical nose twitch.
I thought Tess might have a soft sign or two ofdepression.
She had begun to experience trouble at work-not major trouble,
but something to pay attention to. The conglomerate she worked forhad asked Tess to take over a company beset with laborproblems. Tess always had some difficulty in situations that required meeting firmness with firmness, but she reported being more upset by negotiations with this union than by any in the past. She felt the union leaders were unreasonable, and she had begun to take their attacks on her personally. She understood conflict was inevitable; past mistakes had left 1abor-management relations too strained foreither side
. '". ". .
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to trust the other, and the coaxing and cajoling that characterized Tess's management style would need some time to work their magic. But, despite her understanding, Tess was rattled.
As a psychotherapist, I might have wondered whether Tess's difficulties had symbolic meaning. Perhaps the hectoring union chief and his foot-dragging members resembled parents-the aggressive father, the passive mother-too much for Tess to be effective with them. In simpler terms, a new job, and this sort especially, constitutes a stressor. These viewpoints may be correct. But what level of stress was it appropriate for Tess to experience? To be rattled even by tough negotiations was unlike her.
And I found Tess vu1nerable on another front. Toward the end of one of our fifteen minute reviews of Tess's sleep, appetite, and energy level, I asked about Jim, and she burst into uncontrollable sobs. Thereafter, our meetings took on a predictable form. Tess would report that she was substantially better. Then I would ask her about
Jim, and her eyes would brim over with tears, her shoulders shake.
These are weal reeds on which to support a therapy. Here was a highly competent, fully functional woman who no longer considered herself depressed and who had none of the standard overt indicators of depression. Had I found her less remarkable, considered her less capab1e as businesswoman, been less surprised by her fragility in the face of romantic disappointment, I might have declared Tess cured. My conclusion that we should try for a better medication response may seem to be based on highly subjective data - and I think this perception is correct. Pharmocatherapy, when looked at closely, will appear to be as arbitrary -- as much an art, not least in the derogatory sense of being impressionistic where ideally it should be objective -- as psychotherapy. Like any other serious assessment of human emotional 1ife, pharmacotherapy properly rests on fallible attempts at intimate understanding of another person.
MAKEOVER When I laid out my reasoning, Tess agreed to press ahead. I tried raising the dose of imipramine, but Tess began to experience side effects-dry mouth, daytime tiredness, further weight gain-so we switched to similar medications in hopes of finding one that would allow her to take a higher dose. Tess changed little. .
And then Prozac was released by the Food and Drug Adminiatration. I prescribed it for Tess, for entirely conventional reasons -- to terminate her depression more thoroughly, to return her to her “premorbid self." My goal was not to transform Tess but to restore her. .
But medicaions do do not always behave as we expect them to.
Two weeks after starting Prozac, Tess appeared at my office to say she was no longer feeling weary. In retrospect, she said, she had been depleted ofenergy for as long as she could remember, had almost not known what it was to feel rested and hopeful. She had been depressed, it now seemed to her, her whole life. She was astonished at the sensation of being free of depression.
She looked different, at once more relaxed and energetic-more available-than I had seen her, as if the person hinted at in her eyes had taken over. She laughed more frequently, and the quality of her laughter was different, no longer measured but lively, even teasing.
With this new demeanor ~ a new socia1life, one that did not unfold slowly, as a result of a struggle to integrate disparate parts of the self, but seemed, rather to appear instantly and ful1-blown.
“Three dates a weekend," Tess told me. “I must be wearing a sign on my forehead!"
Within weeks of starting Prozac. Tess settled into a satisfying dating routine with men. She had missed out on dating in her teens and twenties. Now she reveled in the attention she received. She seemed even to enjoy the trial-and-error process of learning contemporary courtship rituals, gauging norms for sexual involvement, weighing the import of men"s professed infatuation with her. I had never seen a patient’s social life reshaped so rapidly and
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dramatically. Low self-worth, competitiveness, jealousy, poor interpersonal skills, shyness, fear of intimacy-the usual causes of social
awkwardness-are so deeply ingrained and so difficult to influence that ordinarily change comes gradually if at all. But Tess blossomed all at once.
"People on the sidewalk ask me for directions!"' she said. They
never had before.
The circle of Tess's women friends changed. Some friends left, she said, because they: had been able to relate to her only through her depression. Besides, she now had less tolerance for them. "Have
you ever been to a party where other people are drunk or high and you are stone-sober? Their behavior annoys you, you can't understand it. It seems juvenile and self-centered. That's how I feel around some
of my old mends. It is as if they are under the influence of a harmful chemical and I am all right – as if I had been in a drugged state all those years and now I am clearheaded.
The change went further: “I can no longer understand how they tolerate the men they are with." She could scarcely acknowledge that she had once thrown herself into the same sorts of self-destructive relationships. “I never think about Jim," she said. And in the consulting room, his name no longer had the power to elicit tears.
This last change struck me as most remarkable of all. When a patient displays any sign of masochism, and I think it is fair to call Tess's relationship with Jim masochistic, psychiatrists .anticipate a protracted psychotherapy. It is rarely easy to help a socially destructive patient abandon humiliating relationships and take on new onesthat accord with a healthy sense of self-worth. But once Tess felt better, once the weariness lifted and optimism became possible, the masochism just withered away, and she seamed to have every social skill she needed. . .
. Tess's work, too, became more satisfying. She responded without defensiveness in the face of adamant union leaders, felt stable enough inside herself to evaluate their complaints critically. She said the
Makeover medication had lent her surety of judgment; she no longer tortured herself over whether she was being too demanding or too lenient. I found this remark noteworthy, because I had so recently entertained the possibility that unconscious inner conflicts were hampering Tess in her dealings with the labor union. Whether the conflicts were real or illusory, the problem disappeared when the medication took effect. “It makes me confident," Tess said, a claim I since have heard from
dozens of patients, none of whom had been given a hint that this
medication, or any medication, could do any such thing. .
Tess's management style changed. She was less conciliatory, firmer, unafraid of confrontation. As the troubled company settled
down, Tess was given a substantial pay raise, a sign that others noticed
her new effectiveness.
Tess's relations to those she watched over also changed. She was no
longer drawn to tragedy, nor did she feel heightened responsibility
for the injured. Most tellingly, she moved to another nearby town,
the farthest she had ever lived from her mother.
Whether these last changes are to be applauded depends on one's
Social values. Tess's guilty vigilance over a mother about whom she had Strong ambivalent feelings can be seen as a virtue, one that medication helped to erode. Tess experienced her "loss of seriousness,” as she put it, as a relief. She had been too devoted in the past, at too great a cost to her own enjoyment of life.
In time, Tess's mother was given an antidepressant, and she showed a modest response – she slept better, lost weight, had more energy, displayed a better sense of humor. Tess threw her a birthday party, a celebration of the mother's survival and the children's successes. In addition to the main present, each child brought a nostalgic
gift. Tess's was a little red wagon, in memory of a time when the little ones were still in diapers, .and the family lived in a coldwater flat, and Tess had organized the middle children to wheel the dirty linens past abandoned tenements to the laundromat many times a week. Were I Tess's psychotherapist, I might have asked whether
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the giftdid not reveal an element of aggression, but on the surface at least the present was offered and received lovingly. In acknowledging with her mother how difficult the past had been, Tess opened a door that had been closed foryears. Tess used her change in mood as a springboard forpsychological change, converting pain into perspective and forgiveness.
There is no unhappy ending to this story. It is like one of those Elizabethan dramas-Marlowe's Tamburlaine – so foreign tomodem audiences because the Wheel of Fortune takes only ha1f a turn: the patient recovers and pays no price for the recovery. Tess did go off
Medication, after about nine months, and she continued to do well. She was. she reported, not quite so sharp ofthought, so energetic, so free of care as she had been on the medication, but neither was she driven by guilt and obligation. She was altogether cooler, better controlled, less sensible of the weight of the world than she had been.
After about eight months off medication, Tess told me she was slipping. "I’m not myself," she said. New union negotiations were under way, and she felt she could use the sense of stability, the invilnerabilty to attack that Prozac gave her. Here was a dilemma forme.Ought I to provide medication to someone who was not depressed? I could give myself reason enough – construe it that Tess was sliding into relapse, which perhaps she was. In truth, I assumed I would be medicating Tess's chronic condition, call it what you will: heightened awareness of the needs of others, sensitivity to conflict, residual damage to self esteem. – all odd indications for medication. I discussed the dilemma with her, but then I did not hesitate to write the prescription.
Who was I to withhold from her the bounties of science? Tess responded again as she had hoped she would, with renewed confidence, se1f-assurance, and social comfort.
I believe Tess's story contains an unchronicled reason for Prozac's enormous popularity: its ability to alter personality.