Brave New Mind : LISTENING TO PROZAC: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self, <i> By Peter Kramer (Viking: $23; 300 pp.)</i>
A decade ago, two books foretold the current state of psychiatry. In “Mind, Mood, and Medicine,” Paul Wender and Donald Klein celebrated the “new biopsychiatry.” Mental illness, they said, once thought to result from poorly functioning defense mechanisms, is now known to result from poorly functioning brain mechanisms. Thanks to drugs, they predicted, people will no longer suffer from depression, anxiety, anger or even the blues. The right drug can be tailor-made to fix those deficient neurotransmitters.
At the same time, with much less fanfare, Jonas Robitscher published “The Powers of Psychiatry,” in which he warned of the potential dangers of medicalizing normal emotional problems. Because drugs are easy to administer, he predicted, too many psychiatrists will prescribe them indiscriminately, without asking what a person might be depressed, anxious or fearful about . Robitscher’s quiet cautions were generally drowned out in the subsequent decade by the noisy enthusiasm of biopsychiatrists, and by the economic juggernaut of drug and insurance companies that were promoting drugs for mood disorders.
Peter Kramer, like many of his fellow psychiatrists, has discovered the wonders of pharmacology, particularly the antidepressant Prozac (fluoxetine). Established antidepressants are called “dirty” drugs because they affect many bodily systems at once and thus have unpredictable results and side effects. Prozac was heralded as a “clean” drug--a ‘Listening to Prozac’ high-tech concoction designed to target a single neurotransmitter in the brain (serotonin) and thus to have specific beneficial effects on depression. Watching his patients thrive on the drug made him a convert--quite a convert, considering that his previous book was “Moments of Engagement: Intimate Psychotherapy in a Technological Age.”
“Spending time with patients who responded to Prozac had transformed my views about what makes people the way they are,” Kramer writes. He called this phenomenon “listening to Prozac.” “I had come to see inborn, biologically determined temperament where before I had seen slowly acquired, history-laden character.”
“Listening to Prozac” grew out of Kramer’s curiosity about two puzzles: How can a medication dramatically alter a person’s sense of self? What does the success of medication tell us about the origins and nature of mood, personality and the self?
I should say right here that as a social scientist, I am familiar with the research on all kinds of therapy--biochemical, psychoanalytic and psychological--but I am not a psychotherapist and have no vested interest in any one approach. I am not opposed to medication on principle; I know harrowing stories of people who spent fruitless years in talk therapy and then were saved by the right drug. But I also know harrowing stories of people who have been dangerously and mindlessly overmedicated for normal troubles. Both errors are common in the current turf war among mental health professionals for the hearts, minds and dollars of people with problems.
Kramer is a wonderful writer, and his readers will learn much about the new research on temperament and personality, biological theories of mood disorders, and the behind-the-scenes stories of how psychiatric drugs were discovered or invented. His chapters, laced with illuminating case studies, chronicle the seemingly miraculous effects of Prozac on compulsion, perfectionism, low self-esteem, stress and trauma, shyness, irritability, anxiety, panic, hypersensitivity to rejection, need for attention, lack of assertiveness and inability to take risks, inhibition of pleasure, sluggishness of thought and dysthymia, a condition of chronic melancholy. While admitting that scientists really don’t know much about the brain, depression or drugs at the moment, Kramer endorses the biopsychiatric prediction that new drugs will one day “modify inborn predisposition” and “repair traumatic damage to personality.”
“As we have access to yet more specific drugs,” he says, “our accuracy in targeting individual traits will improve.”
But “Listening to Prozac” is most valuable for the provocative questions that Kramer asks throughout the book, particularly in the last chapter. Should we provide medication for reasons of “cosmetic psychopharmacology”--not for debilitating mental illness but simply to help patients feel better, think sharper and have a psychological advantage at work? He wonders whether we will end up with “psychic steroids for mental gymnastics, medicinal attacks on the humors, anti-wallflower compound--these might be hard to resist.” He admits that the possibility of reaching into the personality to alter a single trait--to perk up low self-esteem, perhaps, or mental agility--”has worrisome implications, not only as regards the arrogance of doctors but as regards the subtly coercive power of convention.” I’ll say.
Kramer also recognizes the cultural context of emotional problems. Since a personality trait such as “perfectionism” might be normal and desirable in one society (or relationship) but a problem or liability in another, Kramer wonders which should be fixed--the person or the environment. “Should a person with a personality style that might succeed in a different social setting have to change her personality (by means of drugs!) in order to find fulfillment?” he asks.
Many women, observes Kramer, do not have an “illness” of depression; they have a coping strategy that is not rewarded in contemporary society. Should women be given Prozac to help them succeed in an aggressive, combative, competitive system?
Moreover, Kramer recognizes that there might be tragic and unforeseen social consequences of thousands of otherwise rational individual decisions to improve one’s personality through modern chemistry. Do we want a brave new world in which no one suffers from miserable moods or chronic complaints? “Much of the insight and creative achievement of the human race,” Kramer allows, “is due to the discontent, guilt and critical eye of dysthymics.”
And yet, as soon as Kramer raises these challenging questions, he dances away from them. It’s as if he is so excited by the liberating potential of medication and of the biological model of personality that he doesn’t want to hear what his own cautionary side is telling him. So he thinks we can rely on a native suspicion about drugs to save us from overmedicating our personalities--even though he immediately adds that this “may be flimsy protection against the allure of medication. Do we feel secure in counting on our irrationality--our anti-scientific prejudice--to save us from the ubiquitous cultural pressures for enhancement?” I sure don’t. And neither do the drug companies. Eli Lilly is about to market Prozac in larger doses to weight-loss clinics (under the name Lovan) because Prozac may increase energy and suppress appetite. How many women will be “irrational” enough to resist yet another pill that promises slimness? How many people are going to make the effort to fix social institutions if they can take a pill to help them adjust to existing ones?
Kramer actually raises enough concerns about medication to write another book that might be called “Worrying About Prozac.” He correctly dismisses the hysteria that followed Prozac’s early fame--the false alarms that Prozac was turning people into killers and suicides. But his book is full of cautions: the people for whom it doesn’t work, who don’t like losing their rough edges, who report feeling that Prozac numbs the “moral sensibility.” The unpleasant side effects, such as nausea, headache and constant restlessness. The fact that “concern over unforeseen or tardive (late-appearing) effects” is realistic because we don’t know the long-term effects of Prozac--this he announces on the last page of the book.
Kramer’s awareness of the social and ethical issues in biomedical treatments--and his inclination always to try psychotherapy first--shows him to be a psychiatrist of unusual thoughtfulness and restraint, but the evidence is abundant that the majority of his colleagues cannot be relied upon to exercise these qualities. At one conference I attended, a psychiatrist chided his colleagues for prescribing medication “imbecilically,” seeing 8 to 10 patients an hour , and failing to consider the limitations of drug treatment or its long-term consequences.
Kramer’s book is good as far as it goes, but I wish it went further. Readers won’t learn anything about the successful treatments for mood disorders that require neither years of psychoanalysis nor medication. Kramer devotes a tiny paragraph to cognitive therapy, for example, acknowledging only that it is “lately much in vogue”; you bet it is, because it works. Controlled studies find that cognitive therapy--a relatively brief, systematic program of treatment in which people learn how their own perceptions maintain their anxieties and depressions--is often just as effective as medication for most mood disorders, including panic attacks, without side effects and long-term risks. (Again, no single therapy works for everybody.)
I recommend “Listening to Prozac,” but for readers who know little about the relative merits of medication and different psychotherapies, I also recommend some balance: Seymour Fisher and Roger Greenberg’s “The Limits of Biological Treatments for Psychological Distress” (1989), Peter Breggin’s “Toxic Psychiatry” (1991) or Louise Armstrong’s superb “And They Call It Help: The Psychiatric Policing of America’s Children” (1993). When you “listen to Prozac”--or Xanax, or Elavil--in these books, you hear a very different message.
