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

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

I’m Richard Heffner, your host on THE OPEN MIND. And again today my guest is the brilliant young psychiatrist and Associate Clinical Professor of Psychiatry at Brown University 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 describe Dr. Kramer’s new Viking book: “Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self”. And today I want to continue with him our exploration of the issues in medicine, ethics and philosophy raised by his truly compelling study. Dr. Kramer, I’m appreciative of the fact that you’ve stayed here with us for a second program, that’s why I was falling all over my own tongue. You know, there’s so darn many questions that were raised in my reading of “Listening to Prozac”, and in the reading of a lot of other people who have commented on your book, I came across a comment in the Newsweek magazine of 1990 … article about Prozac

Kramer: Yes.

Heffner: You’re quoted as saying, and quotations in the press aren’t always real, or accurate, but say there may be … these are not your words, there may even be a drug that can, and now quote “change people in ways they want to be changed. Not just away from illness, but toward some desirable psychological state” (end quote). And I wonder, question I asked you in the previous program … where do you draw the line? Are we going to do what we presumed only God could do? Are we going to be “self-made” men and women? Are we going to create ourselves, or re-create ourselves?

Kramer: think … I think so. I think we have always had that hope, we certainly have that hope through psychotherapy that well be more the way we want to be, less the way somehow we would have been, just left to the vagaries of genetics and childhood experiences and so on. And I think we’re going to move into an era where we’re able to do some of those things with medication as well. I think we’re there already. I, I do think we’re there already for some people.

Heffner: Now, you make the comparison with the objectives of psychoanalysis

Kramer: Yes.

Heffner: …is that … would, would your psychoanalytic colleagues agree with that?

Kramer: Well, I think that there are different objectives to psychoanalysis. One might be simply insight, self-knowledge and so, and I think medications can in subtle and odd ways be helpful in that, although that’s not what medications target. I think there are other aims of psychoanalysis, which is to make people more resilient, flexible, and better able to assert themselves, to be creative, to be in touch with a sense of authentic self. And I think that medication can do many of those things for people who are a good … who happen to respond to the medications that we have.

Heffner: But, again, you’re more orthodox … psychoanalytic colleagues…

Kramer: Yes.

Heffner: …those who aren’t in the rear-guard, who haven’t gone along at all…

Kramer: Yes.

Heffner: … with this psycho pharmaceutical approach to illness. How would they distinguish the objectives of applications of Prozac and applications over the years of psychoanalytic treatment?

Kramer: I, I guess were asking what psychoanalysis is, and what its goals are, first.

Heffner: MmmHmm.

Kramer: And I think that there can be a certain dishonesty about psychoanalysis where a patient comes in and says, “I’m troubled by this, I haven’t, you know, been creative in the ways I want. Or I haven’t … have these terrible depressions”. And the analyst says, ‘Fine, the right thing to do is psychoanalysis”. But in his or her own mind, the analyst is interested in things like self-realization, insight, uncovering of certain conflicts and so on. Which, to the, to the patient be merely instrumental, but maybe to the doctor become goals. And I think that that is a problematic aspect of psychoanalysis. I don’t know whether it should come with a warning label … you know that, “Warning you may learn more about yourself”, suppose maybe that’s obvious about psychoanalysis. But I think for most people the use of psychoanalysis, or psychotherapy, is to get rid of certain crippling repetitive symptoms, patterns of behavior and so on. And I think that … to the extent that those are the goals of psychoanalysis, medication can play a role. I think there’s a question of “good faith” in 1993. I mean what is “practicing in good faith”? I think everybody … psychoanalysts included, will want to see reality. I mean the “reality principle” is what governs psychoanalysis. And if the reality is that a part of a patients problem is largely biological…however we understand that. Then that just is the reality. There’s a study of shyness by Jerome Kagan at Harvard, and he writes about incidental findings in very inhibited children, socially inhibited children, and some of them have … there’s a preponderance of blue eyes, and asthma and allergies, and I think what happens when a young person with blue eyes and asthma and allergies and social inhibition comes into your office … now, of courser you; could be fooled. They could be inhibited on the basis of some entirely environmental, social developmental thing. But I think you at least have to think, and probably share with the patient, you know, there may be a substantial genetic component in what’s going … you know if you believe those studies. It would be bad faith to say, “Now, lie down and say the first thing that comes to mind”.

Heffner: But why do you necessarily move on from the honest approach of “there may be some genetic predisposition here”. If you are moving on to say there may be some genetic predisposition here, and we can identify it with certain immediate chemical components of your being…

Kramer: Yes.

Heffner: …and we’re going to change those components. Why, why, why move on? The honesty is there in indicating what your analysis of the problem is … your, your diagnosis is.

Kramer: I guess

Heffner: Why do you necessarily move on to the manipulation?

Kramer: The manipulation. Well, let’s say the person comes in and says, “You know I’ve been painfully socially inhibited for many years, and I’d like to get over that”. Now I don’t know that that’s something we can manipulate biologically right now.

Heffner: But that seems to be part of what you’re writing in the

Kramer: Yes.

Heffner: …book on Prozac.

Kramer: I think some people do respond in that way. Although it’s a complicated story because it in research as if the right chemicals to manipulate are, are certain ones, and yet the ones we’re manipulating are other ones. So I’m not quite sure in my own mind exactly why or how these medications affect shyness. This is to go off slightly to a different topic, which is what is it that these modern antidepressants like Prozac and Paxon and Zoloft are doing? Are they really antidepressants, or are they something else. And I think there’s some reason to believe that they may give people a sense of security and wellness and well-being. But that they may not be as truly antidepressants as some of the drugs that have more side effects that have come earlier. May not target depression. And so that giving that sense of security may make a lot of things get less bad … from social inhibition to compulsiveness, to impulsiveness. Whether these are all things that are, are influenced by the same biological systems, and, and that medications like Prozac are influencing all these conditions on a primary basis, or whether Prozac is doing something else like just making the person feel more secure, and incidentally whatever else might go wrong, tends to get better. I don’t know. So I don’t want to say that we have direct treatments for social inhibition.

Heffner: What … what should I call them … religious concerns … might there be about the continuing application of Prozac or other drugs that increase those components in the blood. That enables us to be more aggressive, more out-going, etc.

Kramer: I don’t know. … there’s a … this is not religion exactly, but an old teacher of mine coined the phrase psychopharmacological Calvinism … that people like to believe I suppose because they want to believe that people are most malleable through insight, most properly changed through insight that if you take a drug and get better, you’re going to pay a price. Now, of course, there are lots of prices in terms of physical side affects. But plenty of people take medications and don’t pay a physical price. And then the question is whether you pay a moral price? Whether it’s inherently better to engage in a quest than it is to take a medicine. My sense is that medicines largely move people from one normal human state to another, so that the objection that you’re making people very odd, or not the way God intended, is a difficult argument. Because there are plenty of other people God did intend to be that way. And the next question is whether you interfere with some typical human functions, characteristics or traits … and my impression is that you don’t. The people are plenty willing to quest once they are less inhibited … say. In fact, they may be freer to quest.

Heffner: Angst and sadness and, I was going to say depression, but I, I don’t’ want…

Kramer: No.

Heffner: …to use that word. Sense of alienation, sense of down-ness, aren’t those all necessarily part of the human equation, or would you say “why, they have been considered so, where is it written”?

Kramer: I don’t know that the medications erase angst or sadness, but they certainly do lessen it, or make it less likely that people will have sort of miniature depressions in response to small losses. As was riding down here today, I was reading another wonderful new book, by Kay Jamison called “Touched With Fire” about manic-depressive illness and creativity. And a lot of the poets and artists she writes about may or may not have been manic depressive, but they certainly describe … their descriptions of depression include descriptions of the more minor conditions. Well, you’d say, “Well, everybody has that’. And, and I suppose there’s a question both for artists and for the human race about what happens if we diminish those painful feelings that seem to be associated with creative production. Maybe there are some virtues to suffering. Most societies have thought there were virtues to suffering.

Heffner: And you?

Kramer: I think there are virtues to suffering. People have asked me why I don’t take Prozac myself, why I’ve never tried it, And I, I think partly it’s just a nuisance, these medicines take four or six or even eight or ten weeks to work, and I have trouble … if someone prescribes penicillin for a week, I find I have trouble taking it for the whole week. But to give a less facetious answer, I think that there’s something to be said about playing – – the hand that’s dealt you, about struggling with the, you know, the emotions you’ve grown up with and so on. But there are people who’ve grown up in very rough circumstances where you’d like to say, “Maybe the most moral thing is to give them a little help”, even if it’s biochemical.

Heffner: You know, in our discussion last time and right now, one thought keeps occurring to me that should ask you about your fix, your feelings about genetic manipulation, manipulation in the test tube and how .. whether you have any compunctions about our ability now to identify on the … in the genome work how we can create ourselves in terms of blue eyed, blonde hair, tall, rather than short … thin rather than fat, etc. human beings… aggressive, enthusiastic personalities. How does that mechanical manipulation correspond to your biochemical manipulation.

Kramer: Yeah. I think there’s a complicated … that’s a complicated set of questions in that, you know, what are we talking about? Are we talking about a parents ability to have just the child he or she wants. Well, that’s complicated, think the whole question of how we have children and we own them or don’t own them is, is aroused by that. And in some ways I think we’d like people not to have the belief or illusion that they own their children as much as some people think they do. Medication, at least, in, in the cases we’re talking about is given to someone who makes a decision … I suppose we could ask what right the doctor has to withhold the medication … here’s the fruit of modern science … it is the doctor’s right to prescribe … you know that license in society gives the doctor … you know, where does that come from? Is it to protect people from harm .. if people are well informed shouldn’t they be able to make their own choices as soon as drugs aren’t addictive, and so on. So, I think … in any case, what I’m trying to say is I think there’s a difference in the case of free will of a person choosing to take a medicine, if there really is free will in that, as opposed to manipulating the next generation. On the other hand, we’ve talked about biological materialism in, in the past show and I think along sort of Marxist lines, that the technology really is going to influence the philosophy. That we almost don’t have the philosophy or ethical guidelines to know how we’re going to, to handle it. We, we think we do … how we’re going to handle questions like genetic engineering. I think the world will just look differently. I think the world looks different already in the face of these new medications. And that our sense … that our comfort with these medications once they exit is almost inevitable.

Heffner: So that when I asked you at the beginning of the last program about your fix on the nature of human nature…

Kramer: Yes.

Heffner: Your response really must be ‘no fix … we are what we become”.

Kramer: Well, I think we’re in a period of transition. For instance…

Heffner: That’s what Adam said to Eve.

Kramer: Right. I, I think we, we look at monkey studies, for instance. I wasn’t terribly interested in monkey studies when I was mostly focused on psychotherapy. I mean you, you don’t do a lot of psychotherapy with monkeys. But once it’s clear you can change very salient characteristics with medication, all of a sudden the literature we attend to, the kind of science we attend to becomes different. And the monkey studies … or what we have in common with, with lower animals becomes much more important. So that I think “yes”, it isn’t just that the world around us changes, we change, what we attend to changes, and that the morality that’s going to govern these medications will be to some degree a new morality. You know not that our morality is so different from the morality of the early Greeks. But that there will be changes in how we view these medicines lust because they exist.

Heffner: Well Hollywood plays a major role in our lives … clearly…

Kramer: Yes.

Heffner: Television does. Entertainment does. The “bright and the beautiful”. Therefore they have … those values have created in us a, a “given”, that to be beautiful, I be attractive, etc., etc. in certain ways is a ‘good”. Aren’t you concerned that if you l the present, that we are going to manipulate ourselves in a way that corresponds to whatever the major focus of our times may be.

Kramer: Yes, I do worry about that.

Heffner: But you say “there it is”.

Kramer: Well, I think these medicines have an eerie consonance with certain social ideals, and the social ideals change any … in, in respect to a number of things, like economics, I think that the deal of femininity certainly has changed a great deal even within my lifetime, and certainly a great deal over the past 100 years. Someone who was a sort of a shrinking violet, sentimental Victorian woman would not fare very well today. So that I think that our sense of what is beautiful and what is bright and beautiful, you know changes. I don’t know… I guess we could go further with this and say that … I suppose what I’d say … what is, what is … what is worrisome about these drugs is that once there is an ideal, and you have drugs that can move, move you to that ideal, the question becomes whether anything other than the ideal is unacceptable, is pathologized and so on. I think that is a real worry.

Heffner: It’s not a worry that you carry with you … ah, well, you carry it with you…it appears in your book, but it is not one that is compelling … seemingly. Or it is one that you put on the back of the stove.

Kramer: You know, I, I guess what I have developed over the years is a sense of how unpredictable life is, and how much fun it is to watch, to watch things change. I don’t know that we … I guess what I’m saying is I don’t know that we know what the future of medication will be. I hope it’s not the case that we will produce cookie cutter people, making everyone the same on medication. And I think there’s some reassurance in drugs like Prozac, partly in that they don’t work for everyone, and partly that when they do work, they help people do all sorts of things, diverse things that they want to do…like improve their marriages, or leave their marriage. And I, I just don’t have … I don’t have a grim sense of the future in part because I think we don’t know very well what the future will bring.

Heffner: Wouldn’t it be fairer to say you don’t have a grim sense of the future because, as you’ve just said, what the future brings it will bring?

Kramer: Ah, well, no … I can imagine grim futures, mean it not that … not that I think every future is equally desirable.

Heffner: Yes, but I … I detect from Listening to Prozac” what you’ve written there…

Kramer: Yes.

Heffner: …you have a foreboding about … or you have an uneasiness about an aggressiveness that we might identify with our contemporary capitalist society, let’s put it that way.

Kramer: Yes.

Heffner: …your references to Marx. Why are you willing to participate in a project, in a life work that seems to enhance the very qualities of our society that you have some real compunctions about?

Kramer: I don’t think the life work only does that. First of all, I think there … as I’ve said before that there’s some allegiance to truth and that we have to see what’s before us, whether we love it or don’t love it. And I, but think that I … what I really have is very mixed feelings, I have really a very deep worry about these medications and how they can be miss used in certain societies.

Heffner: Elaborate on that.

Kramer: Well, and let me say the other side also … which is I have a certain fuddy-duddy sense, you know, a sense that I’m being a fuddy-duddy, and that modern society is, is … has its own pleasures and variety that we shouldn’t scorn. That

Heffner: But wait a minute, wait a minute, wait a minute.

Kramer: Yes.

Heffner: We have five minutes left.

Kramer: Alright.

Heffner: Be a fuddy-duddy for a few of those minutes. What are your concerns?

Kramer: My concern is that we demand of people that they be extraordinarily productive, and that you can make people more productive probably with medication, and that if you can do, you will do. That the guy next to you in the office will take the medication, you better take the … the sales manager says “you better take the medication, as well’. And I, I think there are other worries. I think that, you know, we want very cheap health care. Well, these medications are very expensive, they maybe shamefully expensive, but they’re cheap compared to psychotherapy, they’re cheap compared to delicate human contact and they’re, in this sort of scientific-morphic society, they’re, they’re valued more than things like psychotherapy. So that under managed care, managed competition a young woman who’s been say abused in childhood and is only barely aware of it, or not aware of it at all, will come to a doctor and say, “You know, I feel depressed in repeated ways”, and the doctor will say, “You know, all the insurance company will cover is so many pills, and here are the pills”. And this person will never understand why she ticks or how she ticks, and just be given the medication. And I think, I think that is an imminent danger.

Heffner: Well, you talk about the market place … or the work place, rather. I sit next to a colleague of mine … or let’s go back 50 years, when I was starting, and…

Kramer: Yes.

Heffner: …it’s clear that if I’m going to push, if I’m going to be sufficiently aggressive, etc., I’m more likely to get ahead than my colleague, who’s starting out at the same time. He then has the advantage of Prozac. His doctor prescribes it for him. And he then seemingly has a, an advantage, an unfair advantage, and you touched on this

Kramer: Yes.

Heffner: … this, this possibility in the work place. Now, what is your moral solution to that?

Kramer: I don’t have a moral solution…

Heffner: Everybody gets Prozac.

Kramer: I don’t have a moral solution. I think that there is some implicit pressure on you to be more hyperthymic, you know to be more vivacious, and driven and in television certainly there’s that pressure. That around the country on all kinds of local television spots and the more senior people seem to be slow and considered, and the junior people all seem to be sort of bright-eyed and quick-tongued.

Heffner: Sure, because we’re over the hill. They’re just starting.

Kramer: Well, I don’t think just for that reason. I think because the paradigm is changed, you know, of what we want in front of us, the degree of stimulation we want to emerge from our television set, I think has changed also. And … but, you know, I guess when I say I … we don’t know the future that well, we may lurch in one direction, and then it may turn out that stickiness and compulsiveness and slowness and deliberateness, for some reason are socially valued, we discover after all, and that we, we, we then pull back. I don’t see us marching just … just because in the present there’s such a push for; for flexibility and Omni competence I don’t think that necessarily that wave goes on forever.

Heffner: Two minutes left. We haven’t at all talked … last program or this … about the side effects…

Kramer: Yes.

Heffner: …the fact that a number of people have said you don’t address yourself…

Kramer: Yes.

Heffner: …to the question of the negative side effects…

Kramer: Right.

Heffner: …of Prozac.

Kramer: I think I didn’t want to write another book about “should you take it, shouldn’t you take it. Does it cause suicide, doesn’t it cause suicide”. I wanted to write this book about the social and personality implications of the medicines that, which we’ve talked about over the past half hours. Yes, this drug causes side effects, ifs not harmless. It commonly causes nausea, headache and causes even vasculitis, and damage to major organs. It probably does make some people more suicidal … in aggregate it’s a very good drug against suicidality, but some people become agitated, make harm themselves. So it’s not a harmless drug. It is, however, a drug that has made many psychiatrists, not just me, speculate about what a drug that is virtually harmless would look like. I think it was so much … had so many fewer side effects than what preceded it, that it stimulated that line of thought even though it is not at all harmless, can’t be put in the water supply, people shouldn’t take it for, you know, for no reason at all.

Heffner: It’s interesting that I don’t bring the subject up to the very end.

Kramer: Yes.

Heffner: Which must be some indication that I’m carried along by your enthusiasm, and

Kramer: Yes.

Heffner: … the enthusiasm that obviously generated by what you hear when you listen to Prozac. That’s the point at which I say thank you so much for joining me on those programs, Dr. Peter Kramer.

Kramer: Thank you again.

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 today, please write THE OPEN MIND, P. 0. Box 7977, FDR 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 Mullarkey Foundation; The New York Times Company Foundation: and, from the corporate community, Mutual of America.