Sex and Prozac

Billy Gayner, a 36-year-old oil company engineer in Dallas, gazed at the woman sleeping by his side. He had met her just a few weeks earlier, at a church camp, of all places, and here she was curled up once again in his bed. Aggressive and determined, she had taken all the steps to get there, which was just what he needed after his wife left. It was great, except for one problem.

They had been having sex for three weeks and he hadn't had an orgasm. He knew he had things on his mind--the divorce, his parents' illnesses--and she wasn't complaining, really: She had never been with someone who could go all night. But Billy had never experienced anything like this.

The doctor who had put him on Prozac to help him through the divorce told him that the drug couldn't be causing his inability to climax. Prozac had no serious side effects, or so everyone thought; it was being given out like cough drops. The problem, he said, was Billy's depression.

Billy was becoming alarmed, and he began to find excuses not to have sex. His girlfriend thought he had grown tired of her; actually, he'd just had enough anticlimaxes. Eventually, the poison from the bedroom would drive the couple apart. Which was just as well--a short while later, Billy's sex drive completely stalled.

Listen to Charlotte, a New York University student (whose identity, like Billy's and those of the other antide-pressant users in this story, has been disguised). A year ago, after a friend committed suicide, she became distraught, "more upset than I'd ever been." The NYU health clinic referred her to a psychiatrist in Manhattan. "He immediately slapped me on Prozac," she says, "with no medical testing, questions about my prior history or anything. He said, 'This is what you need to function."'

Soon she felt so much better--energized, outgoing, carefree--that many of her friends were scheduling appointments with her doctor. But then she began to feel jittery and anxious and soon was unable to reach sexual climax. "Prozac sort of puts a limit on your feelings," she explains, "as if they are on a shelf that you're not quite able to reach. You're on the edge of feeling good or bad, but you're not quite able to. It's like having a lid inside." Sexual fulfillment is on that shelf, too, she says. "You get to a certain point and it's just a stasis. You can't go beyond it because you're numb. And the sex is going on and on"--she laughs--"and you're slowly getting less and less interested in the whole idea."

Martin, a New York lawyer in his 20s, wrestles with the same problem every day. A Yale grad who imparts an infectious air of optimism, he became a "convert" to antidepressants after reading Listening to Prozac, Dr. Peter Kramer's 1993 best-seller, and watching his dad use that drug to recover from a "mid-life crisis/depression." Last spring he went on Zoloft--a Prozac clone reputed to wreak less sexual havoc. "I probably wouldn't have thought about taking it if I hadn't been around so many people on antidepressants," Martin says. "In my group, there's almost a stigma not to be on the drugs." As his peers got happy, he realized he'd been in "probably a depression" for a year and a half. "I was having problems at work, hating my job, very listless. I had a lot of the symptoms. So I figured, What the hell, I'll give it a try."

But mostly he went on the drug because Melissa, his girlfriend of ten months, told him she'd leave him if he didn't. "He was just miserable about his job," she told me one night over dinner. "And I knew it couldn't possibly be as bad as he was feeling about it. He wasn't working late hours, it wasn't taxing, it wasn't that stressful. His reaction to it was so overblown that it seemed like a symptom of depression."

A statuesque redhead who had segued from Vassar into a high-paying Wall Street career, Melissa wasn't feeling so hot, either. "I was having some sort of seasonal disorder," she says. "I've been depressed, off and on, for four years." Her depressions strike mostly in cold weather, and on "at least three" occasions, Prozac had helped her over the hump. Now she was having symptoms again--crying, sleeping poorly, not wanting to go to work--and it was April. "I was getting pretty alarmed," she says. "So I was like, Screw this. He's on it, so I should just go back on it."

From past experience, Melissa knew that she would soon lose her ability to have an orgasm. "Normally, I climax at the drop of a hat. But it seemed like I didn't have much choice: It was no job and no sanity versus no sex."

Martin, who'd been warned, still found the change distressing. "He started asking, 'What's going on? Am I doing something wrong? You're not that interested in sex.' And I kept saying, 'It's the Prozac, it's the Prozac, it's the Prozac."'

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It wasn't supposed to do that. You were supposed to go on Prozac to improve performance, to sharpen your focus and to function with heightened efficiency. The ideal drug for a performance-minded era, Prozac was the antidote to those annoying personality traits--shyness, oversensitivity, self-criticism--that were previously beyond the reach of modern chemistry. Prozac was great for weathering crises and for use in singles bars, the boss' office, on the tennis court--anywhere you needed to function with all your confidence and verve. Oh sure, it was intended for immobilized souls caught in the grip of an excruciating agony--acute depression. They could have it, too, as long as they left some for the rest of us.

And the great thing about Prozac was that you didn't have to worry about side effects. Or so it said in Dr. Kramer's Listening to Prozac. The author, a Brown University professor of psychiatry and columnist for Psychiatric Times, presents ten case histories of patients who became "better than well" on Prozac. Prozac, Kramer wrote, could "give social confidence to the habitually timid," "make the sensitive brash," "lend the introvert the social skills of a salesman." His patient Tess dropped her taste for abusive married men and filled her datebook with offers from nice, eligible bachelors. Sam, an architect, became "more vitally alive, less pessimistic" and "was able to speak at professional gatherings without notes." The book spent 23 weeks on The New York Times' best-seller list--it's still selling briskly in paperback--and set off a stampede to doctors' offices by readers in search of this anabolic steroid for the head.

Prozac turned out to be extraordinarily useful. The drug loosened the hold of obsessive-compulsive disorders, and not just the garden-variety kind--such as never leaving the house because every time you try, you have to check to see if the oven is off. Prozac worked on such newly recognized exotics as body dysmorphic disorder, which stops you from leaving the house because, for instance, you're convinced your penis is crooked. Prozac also relieved the compulsions of gamblers and bulimics, took the sting out of PMS and combated attention-deficit disorder, arthritis and chronic fatigue.

Prozac "works essentially to dim the pain centers so that they're not registering as much upstairs," explains Dr. Michael Lowney, a Boston physician who prescribes it for back pain. As a bonus, it boosted his patients' spirits, "because people who have back problems can't play golf, or they can't make love or they can't do other things, and then they're depressed." Prozac's "typical effects--assertiveness, vivacity, mental acuity--fit a competitive, business-oriented culture," Newsweek commented. One 39-year-old direct-seller said the drug allowed her to "put on a happy face for Tupperware." Even dogs and cats were being put on it.

Not surprisingly, the purported need for the drug was growing. In the Eighties, people complained of being dysfunctional; after Prozac came out in 1988, everybody decided they were depressed instead. People were now suffering from "atypical" depression, which afflicted high-functioning types who led lives of quiet despair. They were also afflicted by dysthymia, a disabling condition just below the threshold of clinical depression that, according to one recent study, strikes nearly half of the population. Almost all of them may qualify for Prozac. Thousands were sitting in front of light boxes to ward off seasonal affective disorder, the full-fledged depression that winter blahs had become. In 1992, the Journal of the American Medical Association reported that people who were born after 1955 were three times more likely to be depressed than were their grandparents.

"Maybe ordinary people have a lowgrade depression they're not even aware of?" suggests James Goodwin, a clinical psychologist in Wenatchee, Washington. "The statistics just keep going up. They used to say one in 12; now they're saying one in two people apparently have a mental illness at some point in their lives. I just read in (continued on page 88)sex and prozac(continued from page 70)The Wall Street Journal that overweight people may be feeding their depression, and 30 percent of the population is overweight. It's possible that a big percentage of these people have mild to moderate depression they don't even know they have."

"Sexual function comprises three phases: desire, arousal and orgasm. Prozac can wreck all three."

Working through a network of physicians, Goodwin has put upwards of 600 people in Wenatchee (a.k.a. the Apple Capital of the World) on Prozac. "It's probably less toxic than aspirin," he says. He admits that in his wildest dreams he fantasizes about putting it in the water.

But there are naysayers. Dr. Peter Breggin, the author of Toxic Psychiatry, is the psychiatric equivalent of Ralph Nader. He's been called "the conscience of American psychiatry" and, more frequently, a crank. Americans love Prozac because "Americans love speed," he says. "Speed fits with the compulsively driven, shallow-relating, things-are-going-great character of the American personality." Prozac, says Dr. Breggin, is clinically similar to speed; it has the profile of a stimulant drug.

In his new book, Talking Back to Prozac, Breggin calls the double-digit incidence of nervous system symptoms reported in Prozac's clinical trials--headaches, nervousness, insomnia, nausea, diarrhea--indistinguishable from those of amphetamines and cocaine. In a section titled "Listening to Cocaine," Breggin quotes an 1878 advertisement for coca leaf that praises its usefulness for "young persons afflicted with timidity in society." He claims that now adolescents are breaking open their parents' Prozac capsules and snorting the contents.

But Breggin is in the minority. With more than 1 million prescriptions being written each month and worldwide sales of $1.2 billion a year, Prozac was the Jurassic Park of psychiatric medications: the all-time best-seller. After complaints that the standard 20 milligram dose was too strong, Eli Lilly & Co., the drug's manufacturer, brought out a half-strength capsule (for the same price).

In the Eighties, thanks mostly to Prozac, the number of patients receiving antidepressant prescriptions from psychiatrists increased more than 50 percent. Handling the overflow, and writing most Prozac prescriptions, were general practitioners--more than half of whom, according to a 1993 Rand Corp. study, spent three minutes or less with a patient complaining of depression before reaching for their pens. "Listen," one psychiatrist told me, "I had a patient whose veterinarian prescribed it."

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Many antidepressants work by boosting the level of serotonin, a neurotransmitter, in the brain. The more serotonin you have, the more likely you are to feel confident, energetic and secure. If you have less, you slide in the opposite direction. Early antidepressants boosted serotonin, but clumsily, mucking with many other neurotransmitters and producing side effects that included constipation, drowsiness and dry mouth. Prozac, in contrast, was a psychopharmacological smart bomb: It raised serotonin levels while leaving other neurotransmitters alone. The problem was that, unlike most neurotransmitters, which act on limited areas of the brain, serotonin is found all over the brain, and it is involved in just about every higher brain function, including the ones relating to sex.

Sexual function comprises three phases: desire, arousal and orgasm. First there is the desire for sex. Then, there's the mechanics--the ability of a man to get an erection and of a woman to lubricate. Finally, there is orgasm, the point of it all. Prozac can wreck all three. Although much remains to be learned about the neurophysiology of sex, we do know that the pituitary gland (which is controlled by a region of the brain called the hypothalamus) is the key to sexual hormone production. "There are many serotonin connections to the hypothalamus," Breggin points out. Also, "there is serotonin in the spinal cord, and spinal cord reflexes affect sexual function," he says.

Writing in the American Journal of Psychiatry, two Boston doctors of a patient who developed "prolonged, painful erections" after he went on Prozac noted that "serotonin has been hypothesized to be the central nervous system mechanism responsible for the production of penile erections." And in an article in the Journal of Clinical Psychiatry, a team of Chicago researchers observed that serotonin has been shown to have inhibitory effects on ejaculation in animals. Serotonin may also affect muscles involved in orgasmic contractions, the researchers wrote, and may play an important, if still unknown, role in inhibiting other sex-related neurotransmitters.

"What they're really saying is that the brain affects sex, and Prozac affects the whole brain," Breggin explains. "So pick your function."

It was never a secret that Prozac could impair sexual ability. In the data from the Lilly-sponsored clinical trials submitted to the FDA to gain marketing approval, sexual dysfunction was listed as occurring in 1.9 percent of patients. This became the accepted figure, printed on the drug's package insert and in the Physicians' Desk Reference. But as Breggin reports in Talking Back to Prozac, under a category called nervous system effects, "decreased libido" was cited as occurring at a rate of 1.6 percent. Apparently, for the drug company, a disappearing sex drive didn't count as a sexual dysfunction. But if you add the two figures, the true incidence of sexual side effects in Lilly's own studies rises to 3.5 percent.

That's much less than what others were reporting. "Sexual dysfunction occurs in 85 percent of the women and 60 to 75 percent of the men," estimates Dr. Jane Zirin, a Manhattan psychiatrist. "When Prozac first came out, I saw that immediately and called the drug company. I felt they weren't even reporting it, really." She was told by Lilly representatives that the company's experience "wasn't anywhere near what I was seeing."

In a letter published in the February 1993 Journal of Clinical Psychiatry, Dr. William Patterson of Birmingham, Alabama wrote that of 60 healthy, middle-aged men taking the standard daily 20-milligram dose of Prozac, 45, or 75 percent, experienced "retarded ejaculation or ejaculatory incompetence." Other studies published in leading psychiatric journals cited rates between 7.8 percent and 43 percent, with the higher numbers coming from studies in which the investigators bothered to ask the patients about sexual problems.

"One of the reasons they didn't find out about this early on was that nobody thought to ask the question," explains Dr. Randolph Catlin, chief of mental health services at Harvard University. "Gradually people began to say, 'You know, something funny is happening when I try to have sex."'

"A lot of physicians are perplexed when it comes to sexuality," add syndicated health writers Joe and Dr. Teresa Graedon. "Some of them protest that if their patients learned the secret, they would refuse to swallow their pills."

Many patients can't bring themselves (continued on page 156)sex and prozac(continued from page 88) to discuss their sex lives with their doctors. Errors in "the data collection procedure" may have been responsible for underestimating the rate of sexual dysfunction among people on Prozac, wrote Dr. Frederick Jacobsen of the Transcultural Mental Health Institute in a 1992 issue of the Journal of Clinical Psychiatry. His own study of 160 patients yielded a figure of 34 percent. He suggested that Prozac "might be a candidate to treat individuals who have bothersome sexual obsessions or a history of criminal sexual assault."

"They have sex once a week, and it's nothing to look forward to, since their genitals are anesthetized."

Which wasn't exactly how Lilly was positioning it. "The 1.9 percent rate of sexual dysfunction reported in our package literature represents data that have been collected through extensive, well-controlled clinical trials," insists Victoria Murphy, a Lilly spokeswoman. "From our standpoint it's inappropriate and meaningless to compare this vast body of data with information gathered through anecdotal reports and smaller single studies." I wanted to ask her if the patients in Lilly's studies were specifically questioned about sexual side effects, but she said, "We would decline participation in an open-ended discussion."

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I found that women, with their accounts of out-of-reach shelves and vaginas "shot up with novocaine," were more poetic in their descriptions of Prozac sex. Men were blunter, like the 28-year-old dog walker who told me, "It felt like it wasn't hooked up anymore."

Martin, the lawyer who was taking Zoloft to keep in step with his girlfriend Melissa, quickly became sexually dysfunctional. But at least it was still hooked up. "I can still get an erection, though it takes me longer," he says. "But it's almost as if, in a strange way, the sexual aspect is stripped from it. A good analogy is when you wake up in the morning with an erection--it's not a directly sexual thing."

Over the telephone, Melissa had told me that Martin hadn't had an orgasm in five months. Not true, he says. "Masturbation takes longer, but it's still possible"--though pleasureless. He likens his orgasms to "changing a tire" or "going to the bathroom."

Martin and Melissa are emblematic of many of today's young professionals: depressed, on drugs, anorgasmic. But we're not talking O.J. levels of upset. Martin admits that when he went to see the psychopharmacologist, "I was afraid I wasn't depressed enough. I wasn't sitting in the bathtub with a razor at my wrists." He worried, needlessly, that he wouldn't get his prescription.

Last spring, Melissa rejected her therapist's suggestion that she go on a more heavy-duty antidepressant because, "In my mind, I'd be making this huge leap into the truly sick and medicated if I went off the candy everyone is consuming and went on one of the hard-core drugs." She adds, "I'm completely convinced that if we were not in the era of Prozac, I would not be on any kind of antidepressant."

After five months on Zoloft, Martin reports, his "extreme discontent" with his corporate law job is "pretty much gone." But he doesn't know how much of this is because he likes what he's doing now "and how much of it is because you feel so much better, you don't care." Both say that they're more motivated in their jobs and can put in longer hours.

They certainly spend less time in bed. From their previously vigorous sex life--he says seven times a week, she says four--they're down to once a week, and it's nothing to look forward to, since their genitals are anesthetized. "It has basically destroyed our sex life," Martin says. But both say the trauma has been cushioned by their diminished desire to have sex.

With only a month remaining on his six-month prescription, Martin says he's looking forward to going off it, mostly for the sexual reason. Melissa says she'll probably go off then, too, but makes no promises about the future. Martin calculates they'll have three months before Melissa may have to go back on Prozac for the winter, and, touching her for the first time during the interview, says, "We'll mate like rabbits, get as much in as we can and then go back."

James Goodwin, the Wenatchee Prozac enthusiast, takes a different view of the drug's effect on sex. He's been on Prozac for five years. "My wife was so happy with that side effect, and so am I," he says.

One of the things Prozac has taught him is that the human sex drive--particularly the omnivorous, hair-trigger male sex drive--is a psychological disorder. "For eons human sexuality for a great many men has been obsessive and compulsive," he says.

With the advent of libido-killing anti-depressants, however, "that's all changing." People on Prozac don't feel "that compulsive need to be on top of everybody else" or exhibit "that compulsive 'push, push, push, let's-do-it-without-the-intimacy approach,"' Goodwin says. "There isn't that driven need to keep thinking" about sex: "When you're sitting in class and there's an attractive woman next to you, you find yourself able to concentrate on the issues."

Goodwin's claims for the drug go even further. "People get closer and feel closer. They can touch each other," he says. "A lot of rather compulsive males are telling me, 'It's so much easier to be close to my wife now that I don't feel this need to have sex so often. I can lie close to her and she's not afraid of me anymore. She doesn't have so many 'headaches."' Male patients look back in distress at the amount of time they spent mentally undressing women, having sexual fantasies, watching erotic videos. "They say, 'But I've been like this my whole life. You mean to tell me that this was just part of this disorder?"'

To those who complain they've been neutered, he counsels: "Maybe we don't need to have sex so compulsively. When we're taking these medicines, we don't function as well, because the body is saying, 'Slow down. Why not do it just once or twice a month, instead of three or four times a week or a day or whatever?"'

I suggest that there might be an evolutionary or biological reason our sex drives are the way they are. "Maybe there was a reason 10,000 years ago, when we didn't have all of these medicines that are keeping us alive, and when the animals came out and ate us," Goodwin counters. "But I think we're past all that. When was the last time we evolved? Ten thousand years ago. We've got old bodies that are moving into living a lot longer, and I'm not sure we need this hypersexual behavior as much as we used to. There are too many of us on the earth already."

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On the computer bulletin boards of the nation, depressed and medicated e-mailers mull the problem:

"Saying there is anecdotal evidence that Prozac reduces sexual desire is like saying there is anecdotal evidence that the world is round."

"Before Prozac, sex was never over until I was 'done.' Now I couldn't care less if I'm 'done' or not."

"It's harder for me to have an orgasm by my fingers or my boyfriend's tongue. Do I care? Nah."

These forums provide a real public service by imparting information Eli Lilly hasn't shared. Virgin 7808 blasts her boyfriend's doctor for not telling him that Prozac could kill his libido: "We couldn't figure out why an otherwise good relationship fell apart in the bedroom. It nearly destroyed our relationship." Buldoz, who couldn't ejaculate on Paxil, says "some people on the Prodigy network reported less sexual problems" with Effexor, a new drug being touted as "Prozac with a punch." Having made the switch, he's "elated at having it all." Sex tip for the less fortunate: "I bought a vibrator on the recommendation of a friend who's on a tricyclic antidepressant and lithium," reports Ignatz.1614. "It works great, and my sex life is fine."

Of course, not everyone on Prozac finds lowered sex drive to be a problem.

Elizabeth Wurtzel, the 27-year-old author of Prozac Nation, a memoir of her depression and suicide attempts, says that sex on Prozac isn't a problem for her. When she was put on Prozac after a suicide attempt, "It was just so miserable that if somebody had said to me, 'This will impair your ability to have an orgasm,' I would have said, 'Well, it's already pretty impaired."' Going on a psychiatric drug, she says, should be an act of desperation. "If you're at a point where you're going to be bothered about how it will affect your sex life, you probably shouldn't go on it."

But that ignores the fact that people place different values on their sex lives. A mildly depressed person who doesn't particularly like sex--and psychotherapists will tell you there are many such people--may gain more from feeling happier than is lost by giving up orgasms.

On the other hand, "there are people whose moods are very much dependent on their sex life," Dr. Catlin of Harvard says. "Among college students, sexual performance often carries a pretty high load of self-esteem." Not being able to perform can make a depressed person more depressed. "As you get older, into your late 20s or 30s, it's not quite as important, though for some people it is."

"I just saw a gal today whom I had on Prozac," reports Dr. Roger Cranshaw, a psychiatrist and sex therapist in San Diego. "About a month ago I switched her to Wellbutrin, a tricyclic antidepressant. Now she's able to climax and she's more interested in sex. Getting her sex drive back really counted for her, so she's happier."

Further complicating matters are the partners of these Prozac people, whose own sex lives can be wrecked as their lovers or spouses get happier. Every therapist I spoke with told of patients who had to go off Prozac because their partners griped too much or because they felt guilty.

"I think that healthy couples should go on a psychopharmaceutical together," Melissa tells me. "You have to go on it and off it at the same time. What if I were to go off it and he were still on the shit? I'd kill him. It would be the end of our relationship. Because my sex drive would go up, and I don't think I could deal with that situation."

Catlin says, "I've had wives of elderly gentlemen come in and say, 'Please take my husband off Prozac, because he was so much fun when he was able to perform sexually, even though he was depressed."'

I was not reassured by what I was learning of psychiatrists' attempts to deal with this problem. Charlotte, the NYU student, recalls her doctor telling her, "'Right now, I think you should be concerned with other things.' But he said, 'If you're really worried about that, take it every other day.' And I asked, 'Is that going to make a difference? You told me it stays in your system for ten days.' And he said, 'Well, that's true."'

One New York psychoanalyst I spoke with told his patients that they can "go off the antidepressant on Thursday and feel fairly confident about having sex on Saturday." This is equally dubious. "Most people I run into these days seem to be taking Prozac," the doctor says. "The ones I'm dealing with are not extremely depressed--they're not all that ill. They know they can go off the drug safely for two days and then go back on it, and that they'll have a better time on Saturday. And that raises their spirits." But he adds, "I don't pretend to be an expert on drugs." He gives me the name of the Long Island psychiatrist who supposedly invented the two-days-off tactic.

"He said I said that?" asks Dr. Stewart Fleishman, incredulous. "I can't imagine that it could work like that, because there would be too much Prozac left in the person's system. It just doesn't make sense."

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Eli Lilly may deny that Prozac is an orgasm inhibitor, but one of its new applications depends on that effect. Dr. Crenshaw, who worked with sex researchers William Masters and Virginia Johnson in the Seventies, holds a patent on the use of Prozac as a treatment for premature ejaculation.

"It was always seen as a problem that certain drugs can interfere with ejaculation," he says. "I started looking at the other side of the coin--that these drugs may be of good use in treating men who have problems with ejaculating too soon. And I settled on Prozac because it has few side effects and it works marvelously." Patients who always climaxed before entry or within seconds of entering their partners, he says, can enjoy several minutes of pleasurable thrusting. Which is more than a lot of people on Prozac get.

"I'm very up on Prozac, no pun intended," says Dave, a 52-year-old dentist in Carmel, California. "I've been cursed my entire life by having essentially a hair trigger. Dr. Masters got me to where I could go anywhere between ten and 30 seconds. And as I got older, or if I drank alcohol, I sometimes could go a minute.

"I tried biofeedback, creams, you name it," he continues. Then he tried Prozac. "It made a big difference. I could suddenly go anywhere from five to 15 minutes." Last year he went to Europe and met a woman. "It was two weeks of screwing--more than I'd ever screwed before. The best sex of my life." He says his orgasms feel "wonderful."

Here, at last, was a positive contribution Prozac could make to sexual wellbeing, a tool for increasing lovemaking pleasure for a man and his mate.

Unless, of course, she's on Prozac.

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Prozac's days in the limelight may be numbered. Zoloft, the antidepressant that Martin is taking, raked in $450 million in worldwide sales in 1993.

"The Zoloft people have been playing catch-up with Prozac," says Catlin. "I was talking to a Zoloft representative the other day, and she said that it's far superior to Prozac because it doesn't have the sexual side effects. And I said, 'What do you mean? Of course it does.' And she said, 'You don't understand. Zoloft has such a short half-life that if you just plan on sex two or three days in advance, you can stop taking the Zoloft and have sex."

Crenshaw says he now prescribes less Prozac and more Paxil. The new kid on the antidepressant block, Paxil, from SmithKline Beecham, generated $250 million in sales last year. "I like Paxil. It's easy to dose, and I can usually treat the patient's premature ejaculation with a lower dose than I can with Prozac," Crenshaw says. That's probably because it's stronger. In Paxil's clinical trials, 12.9 percent of men had ejaculatory problems, and 10 percent became impotent or anorgasmic or experienced delayed orgasm, sexual dysfunction or erectile difficulties.

"I've been on all three: Zoloft, Prozac and Paxil," says James, a businessman in Baton Rouge who formerly couldn't go more than three minutes without reaching orgasm during intercourse. "Paxil has worked the best. If I want to last 45 minutes to impress a woman, that's fine. I can go for hours. I can go all night." But if that's what it does for an early ejaculator, you can imagine what it does to the rest of us.

The last word on sexual dysfunction and antidepressants will have to await epidemiological surveys, which you can bet the drug companies aren't funding. But if you choose a figure for sexual impairment midway between Lilly's 1.9 percent and Dr. Patterson's 75 percent, you still reach the point where the question begins to shift from "How common is this side effect?" to "Is this intrinsic to the drugs' action?" And the decision to take Prozac or its cousins for happiness enhancement becomes much more problematic, even Faustian. If your sex life is the price you pay for a more confident, less flappable, better-keeled you, are you willing to make the trade?