百憂解帶來的未解之憂、Depression drugs 'do not work'

百憂解帶來的未解之憂A history of psychiatry: from the era of...百憂解帶來的未解之憂A history of psychiatry: from the era of...

百憂解帶來的未解之憂

健康CLYDE HABERMAN2014年10月16日

百憂解是一種選擇性血清素再攝取抑制劑型的抗抑鬱藥物。

Matt Dtrich/Associated Press

說到以藥物手段來醫治生活中的絕望，奧爾德斯·赫胥黎(Aldous Huxley)可謂走在了時代的前面。在赫胥黎1932年的小說《美麗新世界》(Brave New World)中，生活在那個反烏托邦未來世界中的阿爾法、貝塔和其他種姓的人類手頭常備一種名叫「蘇麻」的萬能靈藥，只要一點點就可以驅散生活中的陰霾。「服藥勝過受煎熬。」只要吞下藥丸，負面情緒也隨之煙消雲散。

本周（指9月22日那周）的「Retro Report」（以重新審視歷史上的重大事件為主題的系列紀錄片）的主題百憂解(Prozac)和「蘇麻」當然不是一碼事，但其宗旨卻並無不同：對某些人而言，服用幾毫克這種藥物總比應付生活中的大堆煩惱合算多了。繼回顧了1988年美國禮來製藥(Eli Lilly and Company)推出百憂解的經過之後，這部紀錄片又將視角轉回當下，從化學和文化的雙重角度探討了百憂解及其同類產品在抑鬱症的治療領域造成的巨大影響。由於喜劇演員羅賓·威廉姆斯(Robin Williams)不久前自殺，抑鬱症又成為當今人們關注的熱點。

在20世紀80年代末和90年代，人們普遍將百憂解看作是一種「神奇藥丸」，是那些覺得自己快要沒頂於精神痛苦中的人們眼裡的救生圈。百憂解是一類名為選擇性血清素再攝取抑制劑(SSRI)的新型藥物中的明星產品。其作用基於的觀念為，抑鬱症是由一種名叫血清素的神經遞質不足引起的。只要能提高這種腦化學物質的濃度，好啦，精神一下子就振奮起來了。事實上，已經有成百上千萬人接受了百憂解，並對它的作用深信不疑。抑鬱症導致他們情感麻痹，他們說。而今，他們終於可以清楚地思考並熱情地擁抱生活了——多年來，這樣的感覺還是第一次。

除去其藥理學價值，這種半截綠色半截奶油色的膠囊丸也堪稱商業品牌推廣中的奇蹟，而這尤其要感謝它經過市場考驗的商品名。它的化學名稱為鹽酸氟西汀，這顯然不夠朗朗上口。一家名為Interbrand的公司為禮來出謀劃策，想出了Prozac這個名字。「Pro」聽起來就給人胸有成竹、十分專業(professional)的感覺。「Ac」呢，可以認為它表示「行動」(action)。至於Z，這個字母代表了某種力量，可能還有一點點高科技的感覺。

（在製藥領域，X與Z的地位近似。這兩個字母在取名這種拼字遊戲中享有異乎尋常的地位和價值。絕大多數現代藥物的商品名都包含Z或X，或兩者兼而有之。隨便舉幾個例子，Luvox[蘭釋，亦稱無郁寧]、Paxil[百可舒]、Celexa[喜普妙]、Effexor[郁復伸]、Zantac[善胃得]、Xanax[贊安諾]、Zoloft[左洛復]、Lexapro[來士普]和Zocor[舒降之]等等。這肯定不是用巧合可以解釋的。由此產生困擾也就不足為奇了。Zantac和Xanax，哪個能治胃灼熱，哪個又是用以治療驚恐障礙的？看名字可真分不清。）

但凡事都是三十年河東三十年河西，百憂解也不例外。起初它被尊為靈丹妙藥，還是種十分時髦的靈丹妙藥，後來人們卻又開始強烈地抵制它（或許這種反應不足為奇）。關於SSRI是否會增加某些人，特別是青少年的自殺事件或自殺傾向，精神科醫生提出了嚴厲的質問。目前尚無研究證實兩者之間存在必然的關聯，但是這並沒有打消某些著名的懷疑論者的疑慮，英國的精神病學家戴維·希利博士(David Healy)正是其中之一。他將那些把SSRI類藥物當成救世主的說法貶斥為「生物噪音」。

有人覺得百憂解可以救命，其他使用者則認為它剝奪了人正常的生理感覺。百憂解的一個常見的副作用是喪失性慾。還有一些作家和藝術家聲稱，雖然百憂解將他們從抑鬱症的魔爪之下解脫了出來，卻也讓他們精神恍惚。納齊姆·尼古拉斯·塔利布(Nassim Nicholas Taleb)在他2012年的著作《反脆弱：從無序中受益》(「Antifragile: Things That Gain From Disorder」)中提出：「如果百憂解早在上個世紀就問世的話，那麼波德萊爾(Baudelaire)的「憂鬱」、埃德加·愛倫·坡(Edgar Allan Poe)的浪漫主義情懷、西爾維亞·普拉斯(Sylvia Plath)的詩歌、以及那麼多其他詩人的哀嘆，所有那些有靈魂的作品都將遭到扼殺。」

此外，SSRI的批判者們還懷疑這些藥物的效果是否顯著優於安慰劑。其中一些人質疑單憑血清素水平是否就足以導致或防止抑鬱症。心理治療師加里·格林伯格(Gary Greenberg)就屬於這一陣營，他撰寫過若干本關於情緒障礙的著作。在去年的《紐約客》(The New Yorker)上，格林伯格博士寫道：科學家們認為，「血清素只是影響個人情緒的一個因素，抑鬱症的成因以及藥物的效應遠比化學失衡理論所描述的更加複雜。」

「人的大腦中包含的神經元數量比銀河系中的恆星還要多，」他繼續寫道，「而後續的研究得到的證據大多表明，大腦是藥物很難作用到的靶標。」

廣而言之，這個關於百憂解的回顧性紀錄片提出了這樣一個論題：醫療機構，或者更寬泛一點來說，整個社會是否走得太過，以至於將普通的情感，如悲傷，也納入了病態的範疇。我們是否正一步步地放任自己依賴藥物，以增添生活樂趣——就像小說中的人們依賴「蘇麻」一樣——而放棄了征服真正的疾病？

著名精神病學家彼得·克雷默(Peter Kramer)博士將這種現象稱為「美容式精神藥理學」，就像是自願給情緒問題打上一支肉毒桿菌毒素一樣：即使你並非臨床抑鬱症患者，只要你相信服用百憂解及其SSRI同類可以提升你的自信心，或者能幫助你在推銷會上語驚四座，那又何樂而不為呢？

克萊默博士的同行中有人回應道，我們之所以將人性的正常組成部分當成疾病來對待，就是因為現在有了葯。舉例來說，今天有些人甚至將羞怯也歸入了需要治療的疾病，將其較為嚴重的形式納入了社交焦慮症的範疇。此外，偉哥等促勃起藥物也被當作能提升生活品質的東西而得到大肆炒作。在市場營銷中，它們不僅被推銷給需要治療性功能障礙的男性，還被推薦給身體只是出現了正常衰老的普通人。

如果說SSRI類藥物確實幫助人們克服了某些問題，那麼，使人們不再羞於討論抑鬱便是其中之一。幾十年前，好萊塢明星和其他名人都對這個話題諱莫如深。現在，他們已經可以很習慣地公開談論自己的苦惱了。羅賓·威廉姆斯就是一個例子。

當然，在其他社會領域中，有些人仍然十分忌諱這個話題。例如，有一個人在向自己的妻子承認他在服用百憂解時，警告她不要告訴任何人。「我是說真的，」他說。「要是給不該知道的人聽到點風聲，我就得腦袋後面吃顆鋼製的抗抑鬱葯。」這是《黑道家族》中的托尼·索普拉諾(Tony Soprano)對他的妻子卡爾梅拉(Carmela)說的話。這自然只是虛構作品中的一個極端的例子。但是，在美國人里，恐怕很多都會對別人的看法抱有類似的擔憂，所以他們寧願對自己的抑鬱問題守口如瓶。

本文最初發表於2014年9月22日。

翻譯：任扶搖

When it came to pharmacological solutions to life’s despairs, Aldous Huxley was ahead of the curve. In Huxley’s 1932 novel about a dystopian future, the Alphas, Betas and others populating his “Brave New World” have at their disposal a drug called soma. A little bit of it chases the blues away: “A gramme” — Huxley was English, remember, spelling included — “is better than a damn.” With a swallow, negative feelings are dispelled.

Prozac, the subject of this week’s video documentary from Retro Report, is hardly soma. But its guiding spirit is not dissimilar: A few milligrams of this drug are preferable to the many damns that lie at the core of some people’s lives. Looking back at Prozac’s introduction by Eli Lilly and Company in 1988, and hopscotching to today, the documentary explores the enormous influence, both chemical and cultural, that Prozac and its brethren have had in treating depression, a concern that gained new resonance with the recent suicide of the comedian Robin Williams.

In the late 1980s and the 90s, Prozac was widely viewed as a miracle pill, a life preserver thrown to those who felt themselves drowning in the high waters of mental anguish. It was the star in a class of new pharmaceuticals known as S.S.R.I.s — selective serotonin reuptake inhibitors. Underlying their use is a belief that depression is caused by a shortage of the neurotransmitter serotonin. Pump up the levels of this brain chemical and, voilà, the mood lifts. Indeed, millions have embraced Prozac, and swear by it. Depression left them emotionally paralyzed, they say. Now, for the first time in years, they think clearly and can embrace life.

Pharmacological merits aside, the green-and-cream pill was also a marvel of commercial branding, down to its market-tested name. Its chemical name is fluoxetine hydrochloride, not the most felicitous of terms. A company called Interbrand went to work for Eli Lilly and came up with Prozac. “Pro” sounds positive. Professional, too. “Ac”? That could signify action. As for the Z, it suggests a certain strength, perhaps with a faint high-techy quality.

(X is a pharmacological cousin to Z. Both letters are somewhat unusual, worth many points in Scrabble. It is surely not a coincidence that a striking number of modern medications contain either Z or X, or both, in their names, like Luvox, Paxil, Celexa, Effexor, Zantac, Xanax, Zoloft, Lexapro and Zocor, to name but a few. Not surprisingly, confusion can set in. Zantac or Xanax — remind me which one is for heartburn and which for panic disorder?)

Pendulums, by definition, swing, and the one on which Prozac rides is no exception. After the early talk about it as a wonder pill — a rather chic one at that — a backlash developed, perhaps unsurprisingly. Grave questions arose among some psychiatrists about whether the S.S.R.I.s increased chances that some people, notably teenagers, would commit suicide or at least contemplate it. No definite link was confirmed, but that did not end the concern of some prominent skeptics, like a British psychiatrist, Dr. David Healy. He has dismissed the notion of S.S.R.I.s as saviors as “bio-babble.”

If some users deem Prozac lifesaving, others consider it sensory-depriving. A loss of libido is a common side effect. Some writers and artists, while often relieved to be liberated from depression’s tightest grip, also say that Prozac leaves them mentally hazy. In his 2012 book, “Antifragile: Things That Gain From Disorder,” Nassim Nicholas Taleb offered this: “Had Prozac been available last century, Baudelaire’s ‘spleen,’ Edgar Allan Poe’s moods, the poetry of Sylvia Plath, the lamentations of so many other poets, everything with a soul would have been silenced.”

Then, too, S.S.R.I. critics express doubts that these drugs have proved themselves significantly more effective than placebos. Some among them question the very concept that serotonin levels, on their own, cause depression or prevent it. One psychotherapist in that camp is Gary Greenberg, an author of several books on mood disorders. Writing in The New Yorker last year, Dr. Greenberg said that scientists had “concluded that serotonin was only a finger pointing at one’s mood — that the causes of depression and the effects of the drugs were far more complex than the chemical-imbalance theory implied.”

“The ensuing research,” he continued, “has mostly yielded more evidence that the brain, which has more neurons than the Milky Way has stars and is perhaps one of the most complex objects in the universe, is an elusive target for drugs.”

More broadly, this retrospective on Prozac introduces a discussion of whether the medical establishment, and perhaps society in general, has gone too far in turning normal conditions, like sadness, into pathologies. And have we paved a path — shades of soma — toward wanton reliance on drugs to enhance life, not to conquer true illness?

This is what a prominent psychiatrist, Dr. Peter Kramer, has called “cosmetic psychopharmacology,” a Botox approach, if you will, to matters of the mind: Why not take Prozac and its S.S.R.I. mates even if you are not clinically depressed but believe that they can boost your confidence, or maybe help you make a stronger pitch at the sales meeting?

A response from others in Dr. Kramer’s field is that we are taking traits that are normal parts of human nature and casting them as diseases simply because remedies now exist. For instance, shyness is now regarded by some as a condition in need of treatment. In its more severe form, it is placed under the heading of social anxiety disorder. Then there are those much-heralded life enhancers, Viagra and its erection-aiding cousins. They are marketed not only to men with sexual dysfunction but also to those whose aging bodies are enduring normal wear and tear.

One area of shyness that the S.S.R.I. class has helped overcome is discussion of depression. Decades ago, Hollywood stars and other celebrities dared not touch the subject. Now they routinely go public with their anguish. Robin Williams was an example.

Of course, there are those in other realms of society for whom the topic remains taboo. Take one man who confesses to his wife that he is on Prozac but cautions her to tell no one. “I’m serious,” he says. “The wrong person finds out about this and I get a steel-jacketed antidepressant right in the back of the head.” This is Tony Soprano talking to his wife, Carmela. An extreme example from a work of fiction? Sure. But in all likelihood many Americans have similar fears about what others might think, and keep depression to themselves.

antidepressants, placebo

爭論
全世界過量使用antidepressants, 抗憂鬱症藥--它們絕大多數情況的藥效如 placebo或 a dummy pill 稱為"安慰劑".....不過這些研究多是根據"非住院之病人" 所以"患者"還是要"當心...

(行政院衛生署自殺防治中心統計，自殺近年來一直名列在國人十大死因中，八十四年自殺死亡個案為一六一八人，九十五年自殺死亡躍升為四四０六人，顯示每年自殺死亡人數不斷的攀昇，且自殺死亡又以老年憂鬱症為高危險因子，台南市立醫院由身心科主任林忠義率領的醫療團隊，將 ...)

最新研究：抗抑郁藥“用處不大”

2006年，英格蘭的抗憂鬱藥處方達到創記錄的3100多萬。

最新研究顯示，對大多數患者來說，新一代抗抑鬱藥物的臨床好處不大。
英國赫爾大學的研究結果認為，抗抑鬱藥物只對一小部分處於極度抑鬱狀態中的患者有用。
英國慈善機構SANE精神健康部主管沃勒斯說，如果這些研究結果得到證實，這"非常令人不安"。
不過，抗憂鬱藥百優解（Prozac）和克憂果（Seroxat）的製造商表示，它們不同意這個研究結果。
處方藥克憂果的製造商葛蘭素史克（GlaxoSmithKline）表示，這項研究僅僅對"現有數據中的一小部分"進行了分析。
生產百優解的美國禮來公司（Eli Lilly）則說，"大量的科學和醫學實踐顯示，"百優解"是一種有效的抗抑鬱藥物"。
抑鬱症患者們被告知，切勿在未先諮詢醫生的情況下停止服用抗抑鬱藥物。
發表在《公共科學圖書館﹒醫學》雜誌上的這項研究對47例臨床試驗數據進行了評估。
這些數據來自公開發表的臨床試驗數據，以及未發表的數據。未發表臨床試驗數據是赫爾大學的研究人員通過信息自由法案獲得的。
他們的研究集中在一類被稱為"5羥色胺回收抑製劑"(SSRIs)的藥物上。
這些藥包括氟西汀（又稱百憂解）、維拉法辛（又稱速悅，Efexor）和帕羅西汀（克憂果）等，這些都是英國患者常常服用的抗憂鬱藥物。
2006年，英格蘭的抗憂鬱藥處方達到創記錄的3100多萬，儘管官方抗憂鬱指南強調，這些藥物並非輕度憂鬱症患者的首選藥。
英國國家健康與臨床優化研究所目前正對抗憂鬱藥的使用指南進行重新評估。
英國皇家精神醫學院副主任肯德爾發表的研究報告認為，製藥公司傾向於只對外公布有關藥品好處的資料。
他呼籲強制製藥公司公布所有有關藥品的臨床試驗數據。

Depression drugs 'do not work'

Adam Cresswell, Health editor | February 27, 2008