Pandora’s Box … Antidepressants and the Medicalization of Personality, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Peter D. Kramer
Title: “Pandora’s Box … Antidepressants and the Medicalization of Personality”
VIR: 7/7/93

I’m Richard Heffner, your host on THE OPEN MIND. And those of you who have joined me here over the years know how very often ask my guests to what degree their “fix” art the issues before us is informed by their views on the nature of human nature, their sense of what it means to be a human being.

Well, to no guest could that question be put more appropriately than to the brilliant young psychiatrist and Associate Clinical Professor of Psychiatry at Brown University who joins me today …and about whom no less a psychiatric eminence than Robert Coles has written: “Peter Kramer is a warm, spirited, open (and open-minded) physician who has a thoughtful and wide-ranging mind … and a voice of earnest, unashamed speculation and reflection – subtle, suggestive, clarifying”.

These qualities as well characterize Dr. Kramer’s totally compelling new Viking book: “Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self”. And perhaps in telling us quite what we will learn by listening carefully, creatively to the now widely used antidepressant medication Prozac, Dr. Kramer will reveal his own view of the nature of human nature …and perhaps the level of his own concern about what he writes of as “edging toward what might be called the medicalization of personality”. Dr. Kramer, what are the … what are the ideas about the nature of human nature that inform your book, and your thinking about Prozac.

Kramer: You know I started as a psychiatrist from the poi of view of psychoanalysis. Really had been trained in the humanities more than …earlier than in medicine. And I … as started to see the effects of psychotherapeutic drugs I think I found myself more and more tempted by biological materialism, by the thought that larger expanses of personality … ever-larger expanses were determined by biological underpinnings. And I think Prozac, I’ve seen patients respond very dramatically to Prozac furthered that tendency in myself very greatly. That as I saw parts of people’s personality that I would previously have attributed to the carefully developed self, early childhood trauma, insight, family influences, and so on, that those parts of personality seemed to respond to medication. And I think the book is in part an exploration … it’s in part a quest of my own … asking how much am I willing to really sign my name to those beliefs … to what extent do I really believe that things like self-esteem can be merely biological? They look pretty much biological in some patients.

Heffner: “Biological materialism”, that’s an interesting phrase for a person who is trained in the humanities.

Kramer: Yes.

Heffner: And how comfortable are you now? I mean, I have to admit as I read…

Kramer: Yes.

Heffner: …your book, I have a sense of … I mean it’s a magnificently well written book. It, it … and, and I noticed one thing, each criticism, each review that I have read of…critique, I shouldn’t say “criticism”, comments on the fluidity of your style. I noted some, some uneasiness … now, to what degree is that uneasiness still there.

Kramer: Yes. One of the reviewers said my next book should be called “Worrying About Prozac”. I, I think less and less. I think that what we, as a society, or maybe I should just say that I, as an individual, in any case, are headed toward a more integrated view of mind and body. And that really maybe the problem is that the common view of how people are put together, over the last 50 or 100 years, has vigorously ignored biology … has almost denied what human beings have believed since the beginnings of medical writings. You know, if you look at the writings of Hippocrates, he recognizes the melancholic temperament …melancholia is black bile. And that view that people are governed by internal humors and have their temperaments set very early and that those humors influence a number of things from moods, to physical illness, to level of creativity and energy. That view continues through human history through the Romans, the Middle Ages, right through the 18th century, and only really disappears with Freud and the tremendous and one might say, very optimistic and humane emphasis on experience and self-knowledge that dominates our view of personality over, maybe the last hundred years.

Heffner: But haven’t you now added, and I don’t mean you personally, I mean haven’t those who have worked with the, the drugs that you write about, haven’t they gone a step further … not ‘only recognized the bile…

Kramer: Yes.

Heffner: …but said, “We will discover and make use of the chemical bases for these moods and modes and manipulate human beings…

Kramer: Yes.

Heffner: …if I may use that word, accordingly.

Kramer: I, I don’t say this in the book, I … and I, but I wonder whether I don’t believe it, which is that the discovery of drugs like the modern antidepressants, and particularly these new, very potent and specific ones, signals a change in mankind’s relationship to himself, that we really are able to reach in, and change aspects of temperament … something which certainly wasn’t done easily … maybe it was very hard to do at alt until right now … maybe 30 years ago, maybe five years ago … at some point we have a different ability to regulate ourselves.

Heffner: Well, I … you have in front of you transcripts, as I brought them with me…

Kramer: Yes.

Heffner: …of programs that I did with Dr. Nathan Kline, over 30 years ago…

Kramer: Yes.

Heffner: …when Nathan was first working with the kinds of drugs that you relate to, to now.

Kramer: Yes.

Heffner: And that wonderful first program in ‘57 with Viola Bernard, psychoanalyst to perfection… and Nathan and the seeming opposition of the chemical, biological approach and the psychoanalytic approach to, to human frailties, to human disease. This is not something terribly new.

Kramer: Well, part of it is not new … I said maybe 30 years ago … I guess, dating in 1957 are the first antidepressants. I think at that point the view of mental illness had to change, that over the past 30 years as people saw mental illnesses respond to medication, I think that the purely analytic view that the, the most direct, parsimonious, long lasting way to affect mental illness was through talk … that had to be modified as a result of the, the antidepressants. But I think what is new in the past five years with these much more potent and specific drugs like Prozac, and Paxon and Zoloft, is that we are having to look not just at mental illness, but at normal states.

Heffner: That’s … that, of course, is what the fuss seems to be all about.

Kramer: Yes.

Heffner: We’ve gone over the hurdle. Nathan, Viola Bernard discussing mental illness and chemistry… better living through chemistry … better living in terms of illness, but now you’re addressing yourself to, to something very different.

Kramer: Yes. About three or four years ago, I started writing articles for psychiatrists saying, “Look, you are seeing in your offices what I’m seeing”, and I’m not a researcher, I’m a clinician … and the researchers have looked at these drugs in relationship to classic, serious depression. I was saying, “Patients aren’t just getting over their depressions, they are changing in ways that go beyond recovery from depression”. And there even are patients who, once they’re no longer depressed, come off the medication, start to slip a little bit and comeback into our offices and say, “I’m not depressed, I’m about the way I was before I ever took medicine, before I ever became depressed, but I want to be the way I was on that medicine. That was, was different”. And patients even said … I think… if there was one sentence that made me think about writing this book, it was a patient who came in and said, “I’m not myself”. And I said, “What do you mean, you’re not ‘yourself’.” And she said, “I’m the way I was in the past, but that isn’t myself”. And I said, “You were one way for 35 years and then on this medicine for 5 months you were some other way, and that other way is your real … would you never have been yourself if the medicine hadn’t been discovered…might have gone your whole life and never been yourself”. And I think, I think she said essentially “yes” … that there was some marker for selfhood, that she recognized what was self and what was not self, and that the person on the medicine was herself. And I thought that was remarkable and maybe even correct.

Heffner: You say “maybe even correct”.

Kramer: Yes.

Heffner: You have some questions about that?

Kramer: I think it’s very uncomfortable to think that there are…were people throughout history who never felt themselves, or never were themselves … you know, in the absence of these drugs, which have only been around a few years. I think that seems a…on the one hand it seems a bizarre hubristic kind of statement that we … you know we can produce true selves through medication. On the other hand I think there are people we see who just never are comfortable, it’s as if you had a migraine all your life, and it went it away, you would know that that was a change toward your more comfortable self, or your more true self. That the migraine even, even if t had been with you for many years wasn’t really a part of you that was meant to be there. And I think that some people find that the degree of a minor degree of social inhibition, or inhibition to new experiences, or pessimism, stickiness, sentimentality, that goes away on these medicines really feels like “not self” when it disappears.

Heffner: Well, if there is any truth to the old notion that religion was the opiate of the masses

Kramer: Yes.

Heffner: …to what degree will it be true that Prozac and the new regime of drugs, drugs will be the opiate of the classes. That, that you are fostering…

Kramer: Yes.

Heffner: … values, aggressiveness, entrepreneurial attitudes towards one’s self and the world outside that characterize success in a certain kind of contemporary world. Are you happy with that?

Kramer: You know, I think the expression “opiate of the masses” is interesting. I’m not a great scholar of Marxism, but my understanding is that, that Marx in part felt that religion was necessary because the masses were suffering, and that you should not remove the flowers from the chains that burdened the masses, you should remove the chains. So that religion in, in a certain sense wasn’t bad for his period in history. And I think that there are people who are suffering, and that in the individual encounter the doctor almost has no choice but to try to remove that suffering with whatever tools come to hand.

Heffner: But wait a minute, wait a minute, wait a minute … you say suffering”

Kramer: Yes.

Heffner: …now we’ve moved from treatment of illness to treatment of wellness, but not satisfied with that level of wellness. Isn’t that true?

Kramer: I think we have. I think the indications for pharmacotherapy are moving very close to the indications for psychotherapy. And that, that’s also what new. In other words, we … I don’t think have any great moral dilemma about giving psychotherapy to someone who’s overburdened, who can’t be as flexible as hi or her job and family requirements demand. And I think that we’re coming to the era where we will not be uncomfortable with giving medication for that either. Now why is that? I think right now, when I think about myself and my patients, the reason has to do with mental illness in the background. That as I write about a particular patient whose mother fell into a relentless depression, whose father was alcoholic and died young, and she … when she becomes mildly or moderately depressed, I turn very rapidly to medication in the hopes of sparing her the fate of what may be a family illness of some genetic underpinnings, let’s say. When she comes in the second time and wants help and isn’t really ill, I think I have the luxury in that case of telling myself, “well we’re preventing some chronic relapsing and recurring illness, we’re catching it early”. But I think it’s also true that I am weakening my resistance to using medication for minor indications. Because if it works for her, what about the next person who comes in, who doesn’t have quite that family background, but who responds well to medication.

Heffner: Let me go back to the very first question I asked you, when you say “you’re weakening your resistance”…

Kramer: Yes.

Heffner: What shift in your sense of what it means to be a human being is reflected in your weakening resistance to using these drugs for these, I won’t call them minor purposes.

Kramer: Yes.

Heffner: …but for these non-stopping illness purposes.

Kramer: I think there are … I think there are different ways of answering that. Let’s look at the question of self-esteem. Self-esteem is the most personal of traits, it’s the summary, we imagine, of a person’s successes and failures, it takes into account thoughts about the self … we say a person “thinks well of himself”, or “thinks ill of herself”, and I think it’s only recently that I have been made newly aware of how biological self-esteem is. You know Alfred Adler, one of Freud’s contemporaries, briefly a colleague, and then an adversary, talked about the feeling of inferiority … he felt people on a, basically, a biological basis, unknown biological basis, were burdened with a feeling of inferiority, and that they then might become braggarts, or might become shy in a defensive way against this feeling … this biological feeling of inferiority. But when you see a number of patients have their self-esteem changed fairly rapidly on medication, without a change in their personal circumstances, without a change in the successes or failures they experience, you start realizing how important the feeling of low self-esteem is. And I think that there are people, particularly who have been traumatized early in life, and, and maybe not in these very dramatic ways that you read about now, that trauma is so … you know, incest and so on are so popular to explore, that people have been traumatized early in life, may not have the full range of flexibility, resilience, buoyancy, to feel high self-esteem even in the face of very substantial achievements. So that that one area of personality I think I am prone to think of from a more biological point of view … maybe they would get better with years and years of psychoanalysis, and with successes … marriage, support and so on. But that the most parsimonious way to get to it, after a person’s done a certain amount of self-exploration, hasn’t gotten better, is to give a medication and hope that it will just change as a result of a change in the biology of the brain.

Heffner: But change … when is it … when is it indicated? At what point do you say, ‘Okay, I’m not…

Kramer: Yes.

Heffner: …totally happy with this…

Kramer: Yes.

Heffner: …mechanistic approach … biological, mechanistic approach…

Kramer: Yes.

Heffner: …but now’s the time. When is the time?

Kramer: Well, I think you’re probably talking to someone who’s part of the rearguard. That is, I like to see people be in psychotherapy for quite a while, and then say, “Look, you’ve done pretty well; I think we have a good sense of what’s going on. But, you just don’t seem to be able to take pleasure in things, value yourself”, whatever the particular remaining issue is. “And I think we ought to see whether medication will make this better and there’s a whole rationale for this because it looks as if early trauma really changes the chemistry, and probably the anatomy of the brain. And that people may be injured in a way that’s very hard to change just through new experiences. So that what these medicines do in a funny way is give the person the chemistry of someone who had a happier childhood. And at a certain point, I guess I feel as a doctor, as a healer, I want to be able to do that. However, when I say I’m rearguard, I think there are some people who think this is the first line, that, that what we’re talking about is just so much old maid-ish fussing, and that really if someone comes in, isn’t doing well, the first thing you do is give a drug. And I don’t know that there’s a moral response to that point of view. I have been around the country some now, at book signings or talk shows, and people have said, “You know, I’ve read your book, or I’ve heard you talk about this or that, and I’m some one who just went to my internist and he lust gave me the pill and I’m doing fine. Is there something wrong with that?”

Heffner: And what’s your reply?

Kramer: There is nothing wrong with it. It makes me uneasy, but

Heffner: But if it makes you uneasy…

Kramer: Yeah.

Heffner: …it makes you uneasy, obviously for some sense … because of some sense in your self that there is something … maybe not morally wrong … there’s something in the back of your own mind. If you say you’re in the rearguard here…

Kramer: Yes.

Heffner: What is bothering you about this?

Kramer: Well, I think it may be aesthetic. You know, I … to be honest about it … think it may not be a moral objection, it may be an aesthetic objection … it maybe difficulty in making trans … maybe I’m like one of these patients who has difficulty making transitions that I think that there are social worries about the future. If we can change people in certain ways, are people going to be under pressure to change in those ways? If there’s a medication that makes people more vibrant, and energetic, makes them better salesmen: or politicians in effect. If one person is on it, do all people have to be one it? And F think foreseeing those social difficulties makes me reluctant in the individual case, even though at. a certain point I’ll say, “well in this individual case, it’s right to give the medication”.

Heffner: To become more vibrant, to become better salesmen?

Kramer: Yes. Oh, for that purpose?

Heffner: Yeah. Come on.

Kramer: Well .. ah, yes, I think maybe.

Heffner: Humanist Kramer … doesn’t Sound like him.

Kramer: Well, you know…

Heffner: And in the book, ‘Listening to Prozac”…

Kramer: Yes.

Heffner: …there were many times when I see, feel, read, the sense of dis-ease about this way of handling fairly normal people.

Kramer: Ah, let me say another way of ..: put this rearguard thing in another way. I really am someone whose heart is in psychoanalysis. And who is being convinced by what he sees before him. And I think that is the job of psychotherapy, or psychoanalysis … to be honest. And to be honest according to the truth of one’s own generation. And the truth of this generation is that these medicines work and they work in remarkable ways for lots of people.

Heffner: That’s…

Kramer: But I think that a new psychiatrist being trained today… maybe not just being trained in medical school today, but let’s say someone who right now is at the end of high school and is going to enter college may face medicines without those hesitancies that I have.

Heffner: Can you imagine a world in which increasing numbers of people have become happier, more aggressive, more out-going, more “with it”, and because of Prozac or other drugs. Suddenly, someone comes along and wipes the shelves…

Kramer: Yes.

Heffner: …of all of these pills, all of these bottles, or whatever they are…

Kramer: Yes.

Heffner: …of these capsules. What happens to us then? What happens to us when we are built upon…

Kramer: Yes.

Heffner: … when our sense of ourselves is not built upon the old, unhappiness, which is fairly realistic…

Kramer: Yes.

Heffner: …but built upon Prozac and its counter parts.

Kramer: Well, you see that in individual patients, don’t you? I mean there are people who…

Heffner: I know, you referred to that.

Kramer: … there are people who do well on the medicine, and then have to come off it for some reason or another, or it doesn’t work for them anymore. And they are very regretful. I mean there’s a poignancy to having known what it was all about…

Heffner: That isn’t what I meant, Doctor, I didn’t express myself well…

Kramer: Yes?

Heffner: …I meant … we become a product of our happiness, our assertiveness…

Kramer: Yes.

Heffner: …our ability to get along becomes a product of Prozac, or some other drugs, and suddenly, since they are external to us…

Kramer: Yes.

Heffner: …they’re done away with … some catastrophe. Or some stroke of luck, wipes them all out. What we are left with? We’re drug-less, we’re self-less then.

Kramer: Some of us might be. I think that there are people who, when on the medicine say, “You know, now I know what everyone is talking about. You know, I never understood why people got excited about things. Now I know why they did. I couldn’t anticipate pleasure, now I can anticipate pleasure”. And I guess what I was saying was that sometimes those people really do have to come off medication, and are left with that, you know, no medication on the shelf sense, and it is very poignant because they … I think they are in part robbed of the ability they would have had, you know, without any medication at all to hope that just through insight, or, or effort they were going to get to this state. This state seems so different from the state they’re in, that it’s hard for them to believe that they can get back to it through anything but medication.

Heffner: Our “Brave New World”. I daresay, I think I looked in the index and didn’t find any reference to “Brave New World”.

Kramer: Yes, there was…

Heffner: There was one?

Kramer: No, I don’t think there is. I’ve referred to Soma in an earlier text, and think it was excised…or I edited it out…

Heffner: Why?

Kramer: I don’t know whether that section of the book just didn’t work. But I think that Prozac is different from Soma. I think most of our medical, ethical views of drug taking, and our science fiction views of drug taking involve medication that makes people content to be where they are … valium, miltown, librium, heroin, opium, and I think these new medications are quite different. That they take people and make them more assertive, better able to face the world, that the “Brave New World” would be probably quite perturbed by having the, the … I forget … the ‘Betas”, or whoever it is, to, to be put on Prozac because they would feel they have their rights, and they needed their space.

Heffner: They become Alphas, then.

Kramer: Yes.

Heffner: Do you know, again, I’m, I’m such … I’m in such admiration for the book “Listening to Prozac”, and I hear what you’re saying about being part of a rearguard

Kramer: Yes.

Heffner:…you seem reluctantly to be dragged along by the facts, as you see them.

Kramer: Yes.

Heffner: What … peculiar question … what do you see as the real possibility that you will move back again? What is it that would bring you back to where we were … b.p. before Prozac?

Kramer: Yeah. I don’t know. I say what it wouldn’t be. If Prozac turned out to be a terrible drug, and t turned out that people got cancer from it, or it, you know, caused brain damage in the long run that would not to be interesting in terms of whether the self-esteem is biological, for example. Because if people had that change in sell-esteem on the medication, it is certainly a subject to biological influence. Whether or not this particular drug is a good drug, I suppose I might find that things like temperament and personality are very stubborn, you know that we can influence them for a little … sort of the “awakenings’ phenomenon … we can influence them for a tithe while with medication, but it isn’t just that this medicine isn’t so good, but that no medication does very much … that there’s an enormous inherent stability in. mood and personality. Of course, that would mean they weren’t biological, but it would mean that we’re … that maybe the most parsimonious way to change them isn’t through biology, but through something else.

Heffner: That may be the best place to end this program today, Dr. Peter Kramer, I’m so glad you came. And I hope everybody reads ‘Listening to Prozac” because what it has to tell us is of enormous importance. Thank you for joining me today on THE OPEN MIND.

Kramer: Sure.

Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you’d like to share your thoughts about our program, please write THE OPEN MIND, p 0. Box 7977, FDA Station,.New York, New York 10150. For transcripts, send $2.00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The, Thomas and Theresa Mularkey Foundation; The New York Times Company Foundation; and, from the corporate community, Mutual of America.