Before Our Prozac Era

Our era—the era of the still-iconic Prozac—is not the first to be characterized by the widespread use of prescription mental health drugs. Another period of popular drug use, now largely forgotten, preceded this one. In comparing the two eras, we find a fundamentally different understanding of the drugs and what they are for. Looking back might help us confront the stark limitations of our current approach.

The introduction of Prozac in the late 1980s effectively brought the “tranquilizer era” to an end. That era began in 1955 when the oddly-named Miltown hit the market. Unlike the “major” tranquilizers, such as Thorazine, which were used to treat schizophrenia, Miltown was a “minor” tranquilizer. It was prescribed for nervous problems in the general population. Heavily marketed, it became the fasting-selling drug in American history. People swarmed doctor’s offices demanding a prescription. Its success bred dozens of “me-too” competitors and spurred the development of the succeeding blockbusters Librium (1960) and Valium (1963).

By 1970, 15 percent of Americans (20 percent of women and 8 percent of men) reported using a minor tranquilizer in the past year. Most use was only for short periods or intermittently as needed. But the rate of use then is not so different from the rate of antidepressant use today.

With respect to the meaning of the drugs and what they treat, however, the tranquilizer era couldn’t be more different from our own. Considering how the drugs have been advertised—a good proxy for common understandings—makes these differences visible.

A good example from the earlier era is an ad for the drug Serax, which appeared, among other places, in the Journal of the American Medical Association in 1967. Like Librium and Valium, Serax is a member of the benzodiazepine family of drugs, the most commonly prescribed psychotropic medications from the 1960s to the 1980s. Like the other “benzos,” Serax was marketed for the treatment of “anxiety, tension, agitation, irritability, and anxiety associated with depression.”

The visual half of the two-page spread (see here) shows a woman in distress. She is sitting at a table, trapped behind bars formed by the handles of various brooms and mops and surrounded by other housekeeping supplies—an iron, sponges, a bucket. A child’s bicycle behind her indicates that she is a mother. She appears anxious and her posture suggests tension. Her chin rests on her hand and she is chewing on her little finger; her other hand grips one of the handles. Looking directly at the camera, her eyes appear puffy and sad or perhaps angry.

Addressed to general physicians, the text indicates that this is the sort of patient that is common in their practice—struggling with the demands of raising a young family and “confined to the home most of the time.” For months on end, the ad continues, she has been “anxious, tense, irritable” and although the doctor has offered his “reassurance and guidance,” her symptoms, which “reflect a sense of inadequacy and isolation,” have not remitted. As depicted, the feelings are perfectly understandable. They arise from the woman’s response to her difficult circumstances and the ideal solution, the ad implicitly communicates, would be to alter those circumstances.

Since such change is not within the scope of the physician’s therapeutic purview or responsibility, counseling is indicated as the primary treatment. The medication is an adjunct. It cannot change her situation and provides no cure or promise of liberation. There is no image here of the woman, after taking medication, set free. Rather, what the drug offers is some relief, reducing her anxiety and agitation, and thereby “strengthening her ability to cope.” In time, “as she regains confidence and composure,” some counsel “may be all the support she needs.”

That was in the late 1960s. In 1980, psychiatry adopted a new edition of its diagnostic manual of mental disorders. In the revised manual, disorder categories are defined in terms of symptoms and within an implicitly biological framework. When pharmaceutical direct-to-consumer advertising began to first appear in the late 1990s, it necessarily conformed with this change. In these consumer ads, the sort of problems described in the Serax ad are framed exclusively as symptoms of mental disorders, as something you have, a “real” or “serious medical condition” or “chemical imbalance.” And this biological malfunction is what the drugs address.

An ad for the antidepressant Pristiq that ran, among other places, in Parade in late 2015 is illustrative (not available online, see similar ad here). It carries the headline question, “Does depression hold you back from enjoying your life?” The depression sufferer is represented by a wind-up doll. In the before-treatment image, the doll is dressed in drab-colored clothes and slippers, with a hunched posture and stiff arms—her spring has wound down. The idea, according to the company, is to capture the feeling of depression. The doll simulates, in the words of the ad copy, the feeling of being “sad, helpless, overwhelmed, and uninterested in your favorite activities.” “You may feel,” it continues, “like you have to wind yourself up.”

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In the Pristiq ad, the doll/woman is looking longingly at a large mirror, which does not reflect back her current condition but an after-treatment image. In the mirror, she is shown standing on the platform of a carousel, dressed in sporty clothes, her arm extended to her daughter, who looks up at her lovingly from the back of a bright pink pony. Her husband is there too, with a look of expectant welcome. The mother/wife has been away and has been missed. The drug treatment was the turning point.

In the Pristiq ad, unlike the Serax, the sufferer is shown outside of any context, as an isolated and troubled figure. She (the doll) makes no eye contact. Rather, she is an object of our gaze. There is no understandable social predicament here with which we might empathize. The ad invites us to identify not with a person but with an impairment and with an explanation in terms of a biological condition that robs persons of their agency, prevents them from enjoying life, and may very well cause them to neglect others. Counseling is not mentioned, nor any indication given of how long the drug might be required. The after-treatment image in the mirror represents the promise of a joyful outcome, for there is nothing going on that the medication cannot correct. A better life awaits.

The understanding presented in the Pristiq ad is largely taken for granted these days—that life problems are only “real” if biophysical in nature, that drugs correct such problems, that mental distress has no context, and that talking about problems is an option at most. But all are wrong and have had dehumanizing consequences for those seeking help. As noted in a 2019 editorial in the New England Journal of Medicine, psychiatry has “largely abandoned its social, interpersonal, and psychodynamic foundations, with little to show for these sacrifices.” Biologic research has produced little clinical payoff, leaving the field “plagued by overprescription,” with a “checklist-style” diagnostic system, and a “trial-and-error” approach to “medication management.”

It is high time to rethink the meaning of medications and the treatment of everyday suffering. We had a different understanding earlier. Whatever its other shortcomings, it set mental distress and treatment in their social context. We need that union again.