Hooked on happiness: More women are being prescribed anti-depressants. Are we and our doctors addicted to the quick fix for feeling good?

Shape, May, 2002 by Lisa Lombardi

Perhaps you saw the commercial. First, the visual: a stressed-out woman who looks like she's about to go on a killing spree because her grocery cart is stuck. Then the authoritative voice-over, a hypnotic voice ticking off symptoms that sound suspiciously familiar: Do you have mood swings, bloating before your period? It's not PMS, the ad emphasized, but PMDD, a serious disorder helped by a new drug called Sarafem.

I thought: I have that! Then it hit me: Almost every woman has that. "That ad was misleading -- it sent many women to their doctors saying, 'I have PMDD' when the symptoms in the ad were for PMS," says Marla Ahlgrimm, RPh., founder and CEO of Women's Health America and co-author of Self-Help for Premenstrual Syndrome (Random House, 1998). Manufacturer Eli Lilly and Co. pulled the spot at the U.S. Food and Drug Administration's request, but the controversy surrounding Premenstrual Dysphoric Disorder (PMDD) and Sarafem remains. And it's raising questions about the validity of PMDD as a diagnosis, the logic in treating a woman's normal cyclical changes as a mood disorder, and the swelling ranks of women taking anti-depressants.

At the heart of the furor is one key fact: Sarafem is Prozac. "Many women prescribed Sarafem don't know that and might not choose to take a mind-altering drug if they did know," says Paula caplan, Ph.D., affiliated scholar at Brown University's Pembroke Center for Research and Teaching on Women and author of They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal (Perseus Publishing, 1996).

According to Caplan and other critics, repackaging, renaming and finding a new indication for fluoxetine (aka Prozac) is a less obvious way for a pharmaceutical giant to extend its lucrative patent on Prozac (when a patent is up, the drug is open to competition from lower-priced generics).

Not true, says Laura Miller, spokeswoman for Lilly, who points out that though Sarafem now has an exclusive patent, Prozac itself still went off patent in August. She insists that the company's decision to repackage the drug (new name and color) is based on market research showing that women don't want to take an anti-depressant for PMDD. "Prozac is a well-known trademark closely associated with depression. Women told us they think of their symptoms as part of their menstrual cycles and not anything related to depression," she says. So if women don't want to take a depression medication for premenstrual symptoms, why are so many being prescribed one for those symptoms?

PMDD: PMS or mental illness?

Although few of us had even heard of PMDD before the infamous shoppingcart ads appeared in late 2000, the disorder has been listed in the Diagnostic and Statistical Manual of Mental Disorders since 1987. Its inclusion was widely debated; the psychiatric community was so divided about the disorder that they chose to list it only in the appendix until more research could be done. Fifteen years later, PMDD still languishes in the back of the book.

So what exactly is PMDD? Those who believe it exists, including the American Psychiatric Association and the American College of Obstetricians and Gynecologists, classify it as a severe, debilitating set of mood and physical symptoms afflicting between 3 and 8 percent of women between ovulation and menses. "There isn't a woman out there who at times hasn't felt depressed or irritable before her period. What separates PMDD from PMS is when the symptoms come every month and are so severe it's hard to get out of bed, take care of the kids or go to work," says Vivien K. Burt, M.D., Ph.D., professor of clinical psychiatry at UCLA School of Medicine and director of the Women's Life Center of UCLA's Neuropsychiatric Institute.

Essentially, "it's an extension of PMS," says Joseph P. Martorano, M.D., New York-based psychiatrist and author of Unmasking PMS (Avon Books, 1995); psychiatry has labeled PMDD a separate disorder so they can get reimbursed for treating it.

But don't get him wrong: Based on his work with more than 10,000 women in a PMS clinic he ran for many years, Martorano believes that PMS is a "terribly disabling disease, if left untreated." He just doesn't agree with the rush to brand it a new mental disorder and medicate without first exploring less drastic options. "Initially when drug companies came out with studies, they did trials where women with severe PMS were given 60 milligrams of Prozac a day" he says. "Sixty milligrams is a very high dose." (Many depressed women are helped with as little as 10 milligrams of Prozac; standard dosage is 20 milligrams.) Although selective serotonin reuptake inhibitors (SSRI) drugs like Prozac have fewer side effects than the old-school anti-depressants did, they may cause sedation, loss of sexual desire, sleep and appetite changes, nausea, and dry mouth. The long-term effects aren't known.

In another corner are those who say there's no such thing as PMDD, that it's normal premenstrual changes, depression -or neither. "There's not a shred of evidence that PMDD exists," Brown University's Ca plan says. She cites a 1992 study on PMDD (then called Late Luteal Phase Dysphoric Disorder) symptoms, in which three groups -- women who reported severe premenstrual problems, women with no such problems, and men -- tracked the symptoms they experienced daily for two months. There was no difference among the three groups. "That isn't to say hormones can't affect how we feel," Caplan explains. "But does that make it a mental illness?"