Listening to Prozac

Kramer, Peter. Listening to Prozac: The Landmark Book About Antidepressants and the Remaking of the Self. New York: Penguin Books, 1997.

When it was published in 1993, Listening to Prozac by psychiatrist Peter Kramer became an instant bestseller. Kramer captured a revolutionary moment in psychiatry with the advent of a new class of antidepressants (SSRIs) that included the drug, Prozac. Prozac was released by Eli Lilly in 1987. Kramer’s book caused a sensation because it painted a very optimistic and hopeful picture of Prozac’s nearly miraculous ability to transform people’s lives in positive ways. Prozac was demonstrated to help patients with many types of mental disorders: depression, obsessive-compulsive disorder, eating disorders, substance abuse, and attention-deficit disorder. And it did all of this with very few side effects.

But the book also raised many important questions. Among them is whether or not it is ethical to prescribe a drug that increases a person’s self-confidence, resilience, and energy level even when there is no underlying medical condition. It also forces us to consider whether it is possible for a medication to rob us of the characteristics that make us uniquely human, characteristics that include anxiety, guilt, shame, grief, and self-consciousness. Isn’t a certain amount of depression and anxiety part of the “norman” human condition? Kramer wrote: “In the work of existential philosophers like Kierkegaard and Heidegger, the individual’s struggle with anxiety is the preferred route to self-discovery” (p. ix). Are we not losing sight of something important about ourselves and our conception of self when we view guilt, shame, and grief as things to be treated rather than as seeing them as part of the human condition? Prozac may eliminate illness, but in doing so it may also be eliminating what are perfectly sensible reactions to life’s circumstances. Is the overuse of Prozac an indication that our culture is seeking to anesthetize itself from the inherent pain of human existence?

Kramer’s thoughts on Prozac arise from his interactions with his mildly depressed patients who underwent remarkable positive transformations in personality while on the drug. He makes it clear from the beginning that he is only going to focus on case examples where patients responded to Prozac by becoming “better than well” (p. x). As such, he makes no mention of the non-responders, mild-responders, side effects, or withdrawal syndromes. Kramer is concerned with the ethical issues related to prescribing Prozac, which he considers a wonder drug. In between filling out prescriptions, he grapples with whether we should prescribe drugs to improve on normality rather than to treat pathology. He coins the term “cosmetic psychopharmacology” to describe the former. The transformative power of Prozac on the lives of ordinary individuals leads him to question whether the medicated or unmedicated version is the person’s “real” self. Do the transformations Prozac induces reflect an unnatural idealized social norm or are they unveiling a healthy individual trapped in an unnatural state? Kramer speculates that the true self in his patients is masked by years of depressive illness. Many of them upon stopping the drug would remark, “I am not myself again” (p. 10). For these individuals suffering from mild depression, compulsions, or anxiety, the medicated self ironically becomes the true self despite being in an altered biological state. Kramer believes that Prozac has a positive role to play in the ultimate struggle to understand the self. He believes antidepressant have the power to liberate individuals:

In my experience, many patients, including some who may never have had a diagnosable mental illness, are better able to explore their past and their current circumstances while they are taking Prozac. For these people, to whom medication constitutes help in recovery from childhood trauma or protection from a threat of terrible decompensation, the drug seems to aid rather than inhibit the struggle to locate the self (p. 278).

Key to this text is the concept of “cosmic psychopharmacology.” Kramer wants to know if Prozac should be used to treat those who are not suffering from a mental illness, but still want to enhance themselves. He asks us to consider: “What if we knew that for certain people had a nonaddicting, relatively safe drug that increases alertness, quickness of thought, and verbal and mechanical fluency? Should each person be permitted to weigh the risks and benefits and choose to take the drug, even in the absence of illness?” (p. 245). Prozac is a drug that seems particularly helpful for people who do not have severe mental illnesses, yet whose careers, relationships, and happiness are seriously compromised by problems such as anxiety, social isolation, compulsive behaviors, and low self-esteem. The medication seems to alter parts of the individual’s personality. It is this remarkable ability of a drug to create personality changes that Kramer finds exciting and a little disconcerting (I say a little because he continues to prescribe the drug to the mildly depressed and even some who don’t appear to be mentally ill at all). He also raises the question about how much of our personality is biologically determined.

Due to the success of Prozac, which works on a person’s biology, he begins to question whether personality and temperament are biological characteristics. He writes: “Spending time with patients who responded to Prozac had transformed my views about what makes people the way they are. I had come to see inborn, biologically determined temperament where before I had seen slowly acquired, history-laden character” (p. xii). Much of Listening to Prozac provides suggestive evidence that mental illness can come from problems with brain wiring and chemistry that are either inborn or develop in response to traumatic events or stressors. Even though psychotherapy might help a patient gain important self-knowledge such as understanding conflict and traumatic events and how they have affected the patient’s behavior and thoughts, the patient cannot fully recover without dealing with the biological manifestation of the problem. Moreover, failing to treat the biological component of minor mental illness can be devastating. Kramer describes many research studies demonstrating 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 depression, both of which are extremely difficult to treat.

Kramer describes his first clinical experience with Prozac with a patient named Tess. She succeeded in life despite not having a stable family to support or guide her while growing up. At an early age, she was tasked with the stressful responsibility of having to care for her siblings. Later in life, she developed an unhealthy relationship with an abusive man. When prescribed Prozac, according to Kramer, she “blossomed all at once,” became more relaxed, and had more energy (p. 8). Only on the drug did she truly feel herself she declares, “as if I had been in a drugged state all those years and now I am clearheaded” (p. 8). Her masochistic relationship towards men disappears and she was transformed from a socially awkward woman into a confident and “social butterfly” (p. 11). She found herself to be more successful at her job. After several months, she went off the medication and immediately proclaimed that she did not feel like herself. Kramer agreed to prescribe the drug again, pondering, “who was I to withhold from her the bounties of science?” (p. 10). “[T]here is no unhappy ending to this story,” Kramer declared about Tess (p. 10). This may be somewhat ominous to someone who does not consider a few years to be an adequate measure of a drug’s effectiveness and safety.

Tess’s remarkable transformation on Prozac was not an isolated case. Kramer next introduces another patient, Julia, who suffers from pronounced perfectionism and a desire that all things in her life be orderly. Although Kramer believes that her marriage issues would best be left to a psychotherapist, he goes ahead and prescribes her Prozac. Once she starts taking the drug, she reports that her marriage has improved. The drug also gets her “out of the house and into the workplace,” where she is independent and competent (p. 40). When her dosage is lowered, she becomes pessimistic, prone to anger, and demanding of her family. Like Tess, she tells Kramer that she doesn’t feel like herself. Kramer argues that Prozac makes us rethink both psychiatry and the self because the drug improves people without pain or insight that are typical of psychotherapy. The medicine makes Julia better to the point where she questions the point of seeing a therapist. Instead, the drug makes Julia happier “without any increased self-knowledge” (p. 32). Kramer prefers biological arguments about the functions of mood and dismisses attributing misery in adulthood to a childhood psychological trauma as is typical of psychoanalysis. He provides many more case studies throughout the book and the general consensus is that Prozac makes them the people they should have always been.

Critics have accused Kramer of advocating medication over psychotherapy when it comes to achieving personality changes not directly related to depression, such as improving one’s social confidence or job performance. He answers those critics in the afterword of this book by expressing his wonder at the resilience of psychotherapy as a technology and his insistence on the need to integrate psychotherapy with the new pharmacology. He believes that “psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety” (p. 292). However, this is not the tone that he takes throughout most of the text.

One of the strengths of Listening to Prozac is the way that Kramer addresses his own and others’ misgivings about using Prozac to transform others. A drug that has such power raises important ethical questions, especially when it appears to have no downside—that is, the risks and negative effects that typically must be weighed against the benefits of the drug. In 1993, Kramer was reasonably certain that Prozac had no significant side effects for most patients. However, this has changed and has been addressed in the afterword to the 1997 edition of the book. Sometimes it is only after a drug is approved and is widely used for several 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. The drug is linked to birth defects when taken during pregnancy. In rare events, it can cause suicidal thoughts in some users, especially in the first month or two of use. This potential effect is so dangerous 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. An FDA black-box warning is the most stringent precaution a drug can carry before it is pulled from the shelves.

Overall, his book is informative, well written and engaging. The text mixes scientific information with engaging personal stories from Kramer’s patients. Kramer is deeply thoughtful, not shying away from tackling the concerns expressed by critics of Prozac and is frank in his admission about the moral questions that Prozac’s effects have raised in his own mind.

This book is not without problems though. First there is the issue of using case studies as scientific evidence. Some may argue that clinical trials are more important to understanding Prozac’s efficacy than the anecdotal first-hand accounts of patient’s lived experience. (Although there are many who may suggest that just the opposite is true.) Then there is the bias that is inherent in all of us. A psychiatrist’s expectations may distort her judgement and there is the chance that she will pay more attention to the positive results than the negative ones. Additionally, the psychiatrist only sees the cases she treats. She is not privy to the lived experience of other patients whom she does not see. There are other valid criticisms with the drug itself. A 2014 study found that Prozac was no more effective than monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants or placebos. There have been studies suggesting that there is no evidence of a chemical imbalance in depression. After reading Kramer’s unequivocal support for Prozac, I am also disappointed about some of the issues he did not raise. Namely, the unhealthy interdependencies of Big Pharma, physicians, and insurance companies as well as flawed drug trials. There are important questions to consider with regards to Prozac and drugs alike. Are we as a modern society overmedicated? Are we too eager for a quick fix, a green-and-off-white capsule to deal with our emotional pain? Are we so fixated on “performance” in our capitalist society that we feel compelled to “keep up” with pharmaceutical brain enhancers? What are the essence of self and personhood and what are the philosophical implications of using drugs to alter personality? This book raises these questions but does not necessarily provide any answers.