PROZAC AND PERSONALITY: THE ROLE OF GENETICS
The most exaggerated claim that has been made for Prozac, acknowledging that most psychiatric clinicians and researchers agree on its superb antidepressant effects, is that it can also dramatically alter personality in people without an underlying diagnosable clinical or subclinical depression. According to this popular notion, people who are simply unhappy or don’t like themselves can, by taking a Prozac pill, become outgoing, assertive, sociable, and confident: new personalities with altered inner selves, creations of the dubious field of “cosmetic psychopharmacology.”
Most people, who are helped by Prozac, whether they were only mildly or seriously depressed, just return to their former, non-depressed selves. But some people do seem to undergo a rapid and remarkable metamorphosis. This phenomenon is understandable if one is armed with a full knowledge of the patient’s family history and genetic background. The signs that enable one to predict who these hyperresponders might be are all degrees of moodswing, ranging from the subtle highs and lows on one end of the bipolar spectrum to full-blown manic depression, along with what geneticists call behavioral equivalents of manic depression in the family history which have been shown scientifically to include alcoholism and drug abuse, suicide, gambling, sociopathy, as well as the less commonly recognized behaviors associated with manic excess such as compulsive buying of things not needed, promiscuity, nonstop socializing, excess telephoning without purpose, and finally, workaholism. Depressed patients whose personal or family histories show these tendencies, even in their most subtle, hardly recognizable forms, are the candidates who become Prozac hyperresponders.
Among these hyperresponders (no more than 10% of those taking Prozac), there are basically three types that scientifics classify clinically, according to the patient’s predepressive behavior, and genetically, according to the family history:
• Hyperthymic respondent are patients with depression, ranging from minimal to major, who become energetic, outgoing, assertive, efficient, able to organize and prioritize, and more often than not, able to correct the imbalances in their personal and professional lives once the depression has lifted. After taking Prozac, their depression and anxiety disappear. To all outward appearances, their personalities have changed positively. They feel great, and for good reason. They are their old, energetic, sociable—hyperthymic—selves.
• Hypomanic responders go one step beyond the hyperthymic. These depressives develop even more energy on Prozac, need very little sleep, and tend to work and socialize compulsively, often very successfully. Family, friends, and peers at the office who notice their rapid accomplishments and non-stop activities may respond at first with admiration but later with a feeling that something is not quite right, and they may describe these hyperresponders as wired or slightly crazy. Extremely demanding, impatient, and unreasonable, these patients are prone to sudden, intense enthusiasm, irritation that may turn into bursts of anger, and lack of judgment in areas as varied as money management (they overextend themselves financially and often commit fraud), sexuality, driving recklessly, and excesses of all kinds. The hypo-manic response to Prozac can be both positive and negative. When a patient on Prozac begins to show signs of hypomania, it can become serious and the dose should be immediately lowered or discontinued. The patient may need lithium, but by this time, many have quit treatment only to take a plane to Monte Carlo or Las Vegas.
• Manic responders are clearly recognizable and are extremely rare. They possess an unreasonable degree of energy and niay go for days on end without sleep, to be followed by collapse into depression and physical exhaustion. They are expansive, grandiose, or paranoid, and filled with unrealistic schemes and theories. They may call the White House, begin^suing everyone around them, or try to buy Trump Tower on Fifth Avenue in New York City. Their minds race, and they may become delusional. Their judgment is disastrous and they are unable to function in the workplace or the home. Many of these people are none to alcoholism as well. Mania requires hos-italization because it evolves quickly into manic psychosis with its complex paranoid systems, hallucinations, and delusions (many of which involve the F.B.I.. the C.l.A, and other institutions). This is an infrequent response to Prozac and other antidepressants, new and old, but when it does occur, it requires emergency hospitalization and treatment. This reaction in most cases can be predicted by the skilled psychopharmacologist and avoided by prior treatment with lithium.
The frequency of this last Prozac hyperresponse has not been adequately studied but I would estimate it to be no more than 1% to 2% of all those taking Prozac, depending on the population being studied. In my clinical experience, the more severe the manic episodes or genetic equivalents in the personal or family history, the more likely one is to get an undesirable hypomanic or manic response with antidepressant agents. When a person comes in with such a family history, even if he or she has never shown signs of hypomanic or manic behavior, the prescribing physician must begin gingerly, with a low dose and weekly monitoring. What you’re hoping for is a normal response—i.e., a lifting of depression—or even a hyperthymic response, which some psychiatrists may call transformation In order for this to happen, the genetic potential has to be there.
But occasionally, a chronically depressed person comes in, quickly becomes a Prozac hyperresponder and yet seems to have no past or family history of manic depression or its equivalents.
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