Twenty years ago I read a bestselling book by psychiatrist Peter Kramer called Listening to Prozac. When the book was published, Prozac was a relatively new drug, having been released by Eli Lilly in 1987.
Kramer’s book caused a sensation because it painted a very optimistic picture of Prozac’s almost miraculous ability to transform people’s lives. Kramer’s practice had demonstrated that Prozac could help patients with many types of mental illnesses and problems: depression, OCD, panic anxiety, eating disorders, substance abuse, and attention-deficit disorder—apparently with very few side effects.
Moreover, Listening to Prozac is well-written, mixing the scientific information with engaging personal stories about Kramer’s patients. The writer is deeply thoughtful too; he doesn’t shy away from tackling the concerns expressed by Prozac’s critics, and is frank in his admissions about the moral questions that Prozac’s effects have raised in his own mind.
Are we an overmedicated society?
I wanted to reread Listening to Prozac because I’ve recently been pondering the question of whether modern society is overmedicated. Are we too eager for a “quick fix”, a capsule to deal with every physical and emotional pain? In addition, are we so fixated on performance that athletes feel they must “keep up” with performance-enhancing drugs, and fast-driving business types feel compelled to find their own pharmaceutical brain-enhancers? (Prozac sometimes fits in the latter category.) What about the problem of alcohol and recreational drug abuse? Is this a “self-medicating” solution to psychological pain?
I have a personal reason for being suspicious about a drug like Prozac that apparently has minimal side effects: I’m a long-time user of prescription sleeping pills. I know that they have multiple side effects that can be disturbing, unpleasant, and strange. Another recent influence on me was Salmon Rushdie’s novel Fury, in which Rushdie’s protagonist Malik Solanka makes an eloquent case against taking drugs as a way of coping with violent and painful emotions:
This was a nation for which the daily recitation of pharmaceutical brand names—Prozac, Halcion, Seroquil, Numskul, Lobotomine—was like a Zen Koan, or the assertion of a kind of screwy patriotism: I pledge allegiance to the American drug…Doctors wanted to push you down on your knees and break them, and once you started using those chemical crutches they handed out, you’d never walk on your own two legs again.
Is Prozac a “chemical crutch”?
Kramer would not consider Prozac to be a crutch. Rereading Listening to Prozac enabled me to review the science behind the use of Prozac and other SSRIs (selective serotonin-reuptake inhibitors).
Why isn’t psychotherapy an adequate treatment for milder depression, anxiety, and other mental problems? In fact, Kramer does not discount the importance of psychotherapy; he states:
Psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety.
However, he has seen many, many patients improve dramatically after being treated with Prozac when both psychotherapy or cognitive therapy were ineffective. He explains that many patients need a drug to fix what he calls “biologically autonomous handicaps.”
The biology of mental illness
Much of Listening to Prozac provides suggestive evidence that mental illness can come from such handicaps—problems with brain wiring and chemistry—that are either inborn or develop in response to traumatic events and stress. Even though psychotherapy might help a patient intellectually—to understand conflicts and traumatic events and how they’ve affected the patient’s behaviour and thoughts—the patient can’t recover without dealing with the biological manifestation of the problem.
Moreover, failing to treat the biological component of minor mental problems can be devastating. Kramer describes many research studies showing that if mild depression is not treated, changes can occur in the anatomy and chemistry of the brain. Mild depression can escalate into becoming severe depression or bipolar disease, which are difficult to treat.
Prozac is a drug that seems particularly helpful for people who don’t have severe mental illnesses, yet whose careers, relationships, and happiness are seriously compromised by problems such as anxiety, shyness, compulsive behaviours, and low self-esteem.
Kramer notes that Prozac often acts like a “switch” in the rapidity with which it effects change. For example, one of his patients, William M., had low self-esteem in spite of the fact that he was a successful lawyer with a happy marriage and a witty personality. Psychotherapy did not help him, but he improved dramatically on Prozac. Kramer says that “low self-esteem seems a matter of altered emotional proprioception—a neurological distortion in self-awareness…Prozac seems to allow people to be more realistic about interpreting their self-histories.”
Moral implications of a drug that can change people’s personalities
In the introduction to Listening to Prozac, Kramer asks the question: “How is it that taking a capsule for depression can so alter a person’s sense of self?” He goes on to write several stories about patients whose personalities and lives were changed dramatically (for the better) by Prozac.
Yet one of the strengths of Listening to Prozac is the way Kramer addresses his own and others’ misgivings about the use of Prozac. A drug that has such power raises ethical questions, especially when it appears to have no “downside”—that is, the risks and negative side effects that typically must be weighed against the benefits of a drug. (In 1993, Kramer was reasonably certain that Prozac had no significant side effects for most patients. This has changed—please see below.)
Part of the difficulty lies in deciding where on the spectrum of wellness-disease a person should be in order to benefit from a drug like Prozac. Isn’t a certain amount of depression and anxiety part of the “normal” human condition? Kramer writes, “In the work of existential philosophers like Kierkegaard and Heidegger, the individual’s struggle with anxiety is the preferred route to self-discovery.”
Kramer summarizes some of the key objections to using Prozac as expressed by psychiatric colleagues and the novelist Walker Percy (who was also trained as a doctor). Richard Schwartz, in a 1991 paper, makes the point that using a pill to improve mood can result in a disconnect with reality, with human vulnerability and pain.
Similarly, Walker Percy thought a central flaw of contemporary society is a lack of respect for the emotions of fear, pain, depression and anxiety. Percy’s final book, The Thanatos Syndrome, describes the use of a substance called Heavy Sodium that changed women’s personalities dramatically. Though the book was published before Prozac came on the market, Kramer notes that Percy had created “the art that life imitates”.
According to Kramer, Percy’s writing expresses his belief that anxiety is “a summons to authentic existence, to be heeded at any cost…The person who is anxious and confused is less pathological than the one who is complacent and tranquilized.”
Kramer sees the central metaphor of Percy’s writing as “the quest”—man’s quest for his life’s meaning. Kramer is in agreement with Percy that this quest gives a man his sense of worth. However, Kramer questions Percy’s fear that a drug like Prozac could short-circuit any desire to engage in a quest by removing negative uncomfortable emotions that might act as a stimulus.
Through observing Prozac’s effects on his patients, Kramer has concluded that Prozac aids rather than inhibits what he calls “the struggle to locate the self”. The majority of patients who are changed by Prozac say they would never want to feel like they did before. The “new” self feels “true, normal, and whole”—and medication may be necessary to maintain it. Patients see the drug not as creating a “new” self, but as allowing their “real” self to emerge at last.
Kramer agrees with psychiatrist Mark Sullivan’s suggestion of using “autonomy” as an ethical yardstick by which to judge whether a person should or should not take a certain drug. Rather than the standard risk/benefit analysis, the question might be, “Does the use of a medication promote or retard a person’s capacity to run his or her life?”
Anhedia: Both recreational drug users and Prozac users looking for a “cure”
Another property of Prozac—its usefulness in the treatment of anhedia (the inability to feel pleasure) raises questions about distinguishing between drug use and abuse. Severe clinical depression might be considered the extreme “bad” end of a happiness-sadness spectrum. What about people who tend towards the negative end of the spectrum, but are not what would be termed clinically depressed? The “self-medicating hypothesis” is one possible cause for addictive disorders. Both the Prozac patient and the street/recreational drug abuser might be taking drugs for the same reason: to compensate for diminished hedonic capacities.
Kramer gives some useful criteria for distinguishing between drug use and drug abuse. They include legality, excitation, characteristics of the drugs used, and the relationship of drug procurement and use to the rest of a person’s life. Stimulants (such as amphetamines or crack), opiates (such as heroin), and antidepressants are all hedonics but in different ways.
As Kramer points out, opiates and amphetamines “shortcut” the hedonic process in the sense that the act of taking the drug supplies instant pleasure. This can be contrasted with the pleasure that a person might feel when engaged in an activity that makes them happy, such as running or dancing. Some philosophers make a case against direct pleasure as a goal in life—this is known as the “swine objection” (from John Stuart Mill’s view that hedonism is a doctrine “fit only for swine”). Kramer sees nothing wrong with giving anhedonic people Prozac; the drug simply allows them to experience pleasures that normal people enjoy.
Prozac and enhanced mental acuity
Depressed people treated with Prozac are often not only happier, but report that they think faster and function better at work. This sharpening of mental acuity raises another troubling moral question for Kramer. Why shouldn’t a person who isn’t depressed, but would gain an advantage from sharpened mental acuity, take Prozac? Kramer wouldn’t feel right administering Prozac for this reason alone; yet he has to admit that Prozac often changes people’s personalities in ways that are advantageous in our highly competitive society. He wonders whether psychiatrists are influenced by societal norms when they prescribe medication.
He reminds us how commonly “mother’s little helpers”—Miltown, amphetamines, barbiturates, Librium, and Valium were prescribed in the 50s and 60s. These drugs “…were used to keep women in their place, to make them comfortable in a setting that should have been uncomfortable, to encourage them to focus on tasks that did not matter.” In terms of what I wrote above, these drugs discouraged women from thinking about what their life’s quest might be; the purpose of the drugs was to remove the sense of anxiety and aimlessness that women confined by the “housewife” role might feel.
Conclusion: Prozac in 2013
Rereading my original edition of Listening to Prozac convinced me that drugs play a role (and often a critical one) in the treatment of both serious and borderline mental diseases. The personal stories of Kramer’s patients gave me an increased sympathy and understanding of the ways people’s lives can be crippled by mental illness; unfortunately, in ways that aren’t as obvious (or acceptable) as physical handicaps.
However, my online research made it clear that Prozac and the many other SSRIs that have since become available are not as free of side effects as Kramer’s 1993 book led people to believe. Sometimes it is only after a drug is approved and is widely used for years that side effects and harmful effects come to light. Prozac is now known to frequently cause sexual dysfunction, digestive difficulties, insomnia, sinusitis, and other problems. It sometimes causes suicidal thoughts, especially in the first month or two of use; this effect is so serious that in the United States, Prozac packaging must come with a “black box warning” stating that the danger of suicidal thoughts while taking the drug is particularly likely to happen in young people under the age of twenty-four.
Ironically, the fact that taking this drug comes with costs as well as benefits makes it less likely that it will be used by “normal” people for some of the reasons Kramer was concerned about: to “enhance” mental performance, or to acquire a happier, more outgoing personality.
Prozac remains the third most-prescribed antidepressant in the United States, with 24.4 million prescriptions for the generic form of the drug (fluoxetine) filled in that country in 2010. There seems little doubt that though Kramer advocates administering Prozac in conjunction with psychotherapy, many Prozac users can’t afford therapy. The “pill-popping” solution alone might not be the most effective, but it is the least time-consuming and expensive.
When I went to the reader comments below online articles about Prozac’s side effects, I read a large number of shocking and horrible stories. It is worth remembering that virtually any drug taken by millions of people will elicit severe negative reactions in a certain percentage of them. But these comments serve as a sobering reminder that there is no “free lunch” as far as curing mental illness is concerned. The brain is an incredibly complex and delicate organ; we’ve barely scratched the surface in understanding the intricacies of its functioning.
Stayed tuned for a post about my own struggles with another type of psychotherapeutic drug: sleeping pills.