Two to Six Weeks

I

Of the first human body that received fluoxetine almost everything is known except who they were.

The molecule was synthesised in 1972 in a laboratory in Indianapolis. The compound had a number before it had a name. That same year it was verified in animal tissue that it did one very particular thing and nothing else [leaving serotonin outside longer, without touching anything else]. That selectivity was the finding; the antidepressants there were then moved half a dozen things at once and it showed in the body of whoever took them. The first administrations to people are from 1976. Then came the trials with depressed patients, double-blind and against placebo, with their tables, their dropouts and their counts. The approval came on 29 December 1987 and it reached the pharmacies the following year.

In the published reports there is not a single name. There is an n, some inclusion criteria, a mean age, a dropout rate and a list of adverse effects ordered by frequency [nausea right at the top, as it still is today].

It is not that the archive was neglected. It is that the protocol demanded it, and that is why the subjects appear as what the method needed them to be, cases comparable with one another.

II

The date on which that became compulsory can be pointed to, and it is very close.

In July 1972 the United States press exposed what had been going on for forty years in Macon County, Alabama: three hundred and ninety-nine black men with syphilis observed without treatment since 1932, to see how the disease progressed untouched. Penicillin had been available since the forties and was not given to them. The study was closed that same year, when it came out in the newspapers and not before. Nobody inside it stopped it in forty years; it was stopped by the pages of a daily and by public shame, which is a slow, expensive and fairly unreliable control mechanism.

From there comes, two years later, the law that requires ethics committees, informed consent and the anonymity of subjects; from there also comes the fact that the bodies of 1976 have no names.

The coincidence of dates is not an irony: it is a relation of cause. The molecule was synthesised the same year the Macon County business was made public, and by the time it reached people, the system was already set up so that none of them would count separately.

Thompson has a name because in 1922 there was none of this. There was a boy of fourteen, a cloudy extract and a room.

The anonymity is not a hole in the record. It is the protection, and it was bought with what was done to three hundred and ninety-nine men who did have names.

III

The box carries twenty-eight twenty-milligram tablets and at the pharmacy it cost less than three euros. It is an object of a modesty offensive for what it does. Thin card, aluminium blister, a leaflet folded in eight that nobody unfolds whole and a green and white pill that can be swallowed without water if need be.

The first week nothing good happens. Nausea in the morning, the jaw clenched in a way you feel the next day in your temples, sleep broken at a quarter past four with clockwork precision. Sweat. Odd yawns, many of them, mid-afternoon [nobody warns you about the yawns and they are the first thing to appear]. None of that is the effect; it is the body protesting at the interruption.

By the third week I began to notice that things went on being just as bad and I minded slightly less. It is not happiness; it is that the floor rises.

By about the fifth, the morning stopped having that half past seven moment in which one calculates how many hours are left until one can go back to bed.

Of that improvement there is nothing to tell, and that is the problem with writing about this —what the drug does well produces no scenes—. It produces ordinary mornings, which is exactly what one wanted and exactly what cannot be narrated.

IV

Between two neurons there is a gap of some twenty nanometres, and through that gap serotonin is thrown when the first wants to say something to the second. What is poured out does not stay there long. In the wall of the one that released it there is a pump that sucks it back in to be reused, and that collection is extremely fast: a matter of milliseconds.

Fluoxetine sits on the pump. It does not break it or poison it; it wedges on top and occupies it, so that the serotonin already outside stays outside longer than it was due to.

That happens on the first day. From the first pill.

If the block is immediate and the relief takes two to six weeks, then the relief cannot be the block. What the drug does in minute one is not what cures. What cures is what the installation behind it does over the following month, while it holds up under that quantity of serotonin it was not expecting. The receptors on the other bank readjust: some withdraw, others change in number, and the whole circuit slowly reorders itself to work with what there is [weeks, not days, because that is how long a cell takes to make and withdraw pieces].

That reordering is the treatment. The molecule only sustains the condition for it to happen, and then it stays there, week after week, because if it leaves, the installation comes back.

In that same wiring there is another thing connected, and it cannot be separated. Orgasm is a reflex, and like every reflex it has a threshold and needs some signals to go up while others go down. Serotonin is one of the ones that has to go down. It is the brake.

The drug keeps the brake on.

V

The eighth week was the first time, and I did not count it as a problem because it was almost comfortable.

She was on top, it had been going well for a long while, and on reaching the point where normally there is no turning back, there was no point. Everything was still there [the erection, the desire, the wanting, the breathing]. What was missing was the end, which is a thing one does not know is a separate act until it separates.

Forty minutes [I counted them afterwards, by the bedside clock, because I had already become somebody who measures]. Then a kindly pause, one of the sentences said in such cases, and to sleep. The next day, the same. The following week, the same.

The odd part is not the absence. The odd part is that the desire does not go with it. The body wants the same as always, with the same urgency and the same temperature, and gets to within a metre of the place and stays there, looking. Within a week you learn to stop earlier, naturally, like somebody who stops ordering pudding.

I told the doctor in an eleven-minute appointment. He told me three things, all of them true: that it is frequent, that “in most cases” it reverses on stopping and that we should assess whether it was worth it. It was worth it. I said so out loud and came out with the prescription renewed for six months.

There is the signature. Nobody deceived me, nobody hid anything from me, the information was in the leaflet, in small and truthful print, under the heading “common” and with its percentage beside it. But the signature is given before knowing what is being signed, because both effects take the same time to appear. When the good one arrives, you are already five weeks in; when the other arrives, you are eight weeks in and you have been better for three.

Nobody gives that back.

And there is a fine asymmetry in the contract. The benefit is felt in the part of the day one shares with everybody [work, the table, the street], and the price is paid in the only part not shared with anybody except one person. That is why it is signed so easily, and that is why almost nobody mentions it afterwards.

VI

It is the first molecule of mass consumption that trades one thing for another inside the same body, with both on the table. Sadness is not traded for pleasure, because the pleasure stays whole and so does the desire. Sadness is traded for a reflex. People sign, and sign truly, knowing, choosing and renewing the prescription every month.

There is besides a detail of measurement that is worth the whole business. When the studies wait for the patient to report it on their own, the sexual effects appear in one in ten people, more or less. When they are asked directly, one by one and with a list in front of them, they appear in half or more than half [the difference between those two figures is a fact about us, not about the molecule].

The drug is the same. What changes is whether somebody asks.

That gap has a simple explanation and none of them is reassuring. A man of fifty-two with a severe depressive episode does not put his hand up in the consulting room to say he has not come in six weeks, nor does a woman, and the doctor, with eleven minutes per patient, does not open that drawer either if it is not on the form. The effect existed all the same. What did not exist was the line to write it on.

VII

I went on taking it. I took it for another year and a bit, and there were months in which it was the only thing that prevented things I am not going to relate here. Writing wryly about the erotic price of an antidepressant from the other side of the episode is easy, and whoever is inside one will read this and know perfectly well that they would trade anything.

The second objection is worse and goes against the whole piece. What I have spent ten paragraphs pointing out —that the bodies of 1976 have no names— is precisely what makes us know this works. If those subjects had names and biographies, we would have anecdotes instead of a reliable drug. I took my pill with the calm of knowing that it works, and that calm was paid for by them being a number.

There is no way of having both. A choice is made, and it has already been made; it was made in 1974, with the law newly written and the scandal still warm.

VIII

In the reports of 1976 the name is missing and something else is missing: nobody asked about this. The scales in use measured mood, sleep, appetite and anxiety, and sexual life was not a section, so that what is not asked does not appear in the table and what does not appear in the table does not exist in the file. The effect had been there from the first trial, in the same anonymous bodies, waiting for somebody to think of asking.

It took years for them to ask. In 2019 the European regulator accepted besides a more uncomfortable thing: that in some cases it does not reverse on stopping.

1972, synthesis of the compound and exposure of the Macon County business.

1976, first people, without names, as the protocol required.

29 December 1987, approval.

2019, the product information admits that sexual dysfunction may persist after stopping the treatment.

Box of twenty-eight twenty-milligram tablets, generic: less than three euros.