In 1988 the anti-depressant Prozac arrived and made a huge impact on both the pharmaceutical market and the culture. We have heard virtually everything about the drug: that it makes some people "better-than-well," and that it is to blame for the murders committed by one of the Columbine killers.

Of course the truth lies somewhere in between, but considerably closer to the benign end of the spectrum.

Are Prozac and its relatives, Paxil, Zoloft, Effexor, and Luvox, free of side effects? Of course not. But lawsuits have been charging that these medications have caused people to kill themselves, to kill others, and even to rob banks.

As a psychiatrist, I have prescribed these anti-depressants to hundreds of people. Formally, they are classified as SRIs (serotonin reuptake inhibitors) and, yes, there can be serious side effects, but those are very rare.

Over the years, a number of anti-Prozac books have appeared. Last spring, Prozac Backlash written by a psychiatrist, Joseph Glenmullen, was published and renewed the controversy over SRIs' safety. The claims made in that book fostered needless alarm. When there is needless alarm, of course, patients suffer. The book's claims of induced suicide, homicide, and crippling neurological disorders are vastly oversold. If I were a patient taking Prozac, I would flush my pills down the toilet after reading Glenmullen's book. I do agree that Prozac has been embraced perhaps too enthusiastically as a panacea for the human condition, but it has also extended the treatment of depression in positive ways. No longer are anti-depressants reserved for the most profoundly depressed.

Why have Prozac and similar drugs been used more liberally than their predecessors? First, they have fewer side effects. Blurry vision, low blood pressure, and sedation were common problems with earlier antidepressants like the tricyclics and monamine oxidase inhibitors. In the case of monamine oxidase inhibitors, patients had to adhere to a special diet to avoid risk of stroke.

Also, they are much less dangerous in overdose, something one worries about with people who may be suicidal.

Many depressed people who probably couldn't tolerate the side effects of those earlier anti-depressants have benefited. I do suspect, however, that the threshold has been lowered too far in some cases--such that individuals who didn't need anti-depressants, whose mood would have resolved on its own, or who would have responded well to psychotherapy alone--were put on medication.

Most people who ask for SRIs are depressed. But Peter Kramer's book, Listening to Prozac, talks about the phenomenon of "cosmetic psychopharmacology" in which personality traits like shyness, perfectionism, lack of confidence, fear of intimacy, over- or under-competitiveness, even jealousy are "cured" by Prozac. Psychiatrists' prescribing of Prozac for these purposes has, not surprisingly, come under scrutiny by the profession and the pundits alike, but the most dramatic controversy has been spurred by allegations of the violent urges that Prozac and other SRIs may produce--suicide as well as assault and murder.

There have been cases of people who kill themselves on Prozac. This is tragic, but it is far from a shock. After all, who are the recipients of these drugs? The risk of suicide in the general population is 1% in the depressed population it is 15%.

One of the very first things that medical students learn is that patients are at a higher risk for suicide right after anti-depressants of any kind are initiated. Why? Because the various symptoms of depression don't resolve all at once and frequently what's first to improve are the energy level and sleep. And if a patient's energy returns but he is still utterly depressed he can mobilize himself sufficiently to attempt and complete suicide. Also, it is not unusual for patients to look a lot brighter once they have made the decision that they are going to kill themselves. They have a paradoxical mood lift, because they feel they have resolved their problem. Psychiatrists are trained to watch for this.

There have been some reports of people committing suicide on antidepressants who hadn't previously entertained suicidal thoughts. One of the most compelling theories behind this is a side effect called akathisia, which is a profound kind of restlessness. Patients will describe feeling like their organs are writhing in their body and they just have to move. Akathisia can be so distressing as to drive a patient to suicide.

No one had reason to believe that the Prozac-type drugs would cause this side effect. It was heretofore associated with anti-psychotic drugs. But within the last decade some patients on anti-depressants did develop akathisia.

This is so rare: At least three million people a year take these medications. Over a 10-year period one study found 92 case reports of these side effects. It's a tiny percentage. But, of course, when it happens it's spectacular.

The very important point is that these phenomena don't start overnight. The intense agitation develops over a course of days or weeks. And that is why it is so important for the psychiatrist to follow the patients carefully.

That is the key: These medications are not so risky that they shouldn't be prescribed, but they should be prescribed by people who are knowledgeable and have the capacity to hospitalize a patient if the situation turns dire.

Finally, you're probably familiar with the more common side effects of SRIs: insomnia, nausea, decreased appetite, and impaired sexual functioning. These are often trade-offs that patients are willing to endure until their mood improves. And it is a good trade-off for them.

These medications help millions and millions of people. Are there some side effects? Yes. But the more dramatic incidents are enormously rare, and it is clear from the literature, and from my experience in the clinical world, that the benefits far outweigh the risks.