Editorial Note: Kramer v Kramer had been a hit movie a decade earlier. Listening to Prozac offered a chance to have a review called Kramer v Kramer but the journal – Psychological Medicine – was not amused and ditched the title. Here’e the review written at the same time as the Porter and others. In a later post I will try to explain what puzzles me about the Porter and other reviews.
For what will surely prove to be a brief (although potentially recurring) period, the history of Western psychiatry is at present bracketed between books by authors with the surname Kramer; beginning with Heinrick Kramer’s Malleus Maleficarum and closing with Peter Kramer’s Listening to Prozac. Asking the Kramer vs Kramer question – which of these two parents would more of the children chose to live with – would not, one suspects, provide an overwhelming vote in favour of “progress”.
It seems unlikely that either Kramer consciously set out to produce or perpetrate myths but both would appear to have done so rather successfully. In the case of Peter Kramer, there is for example the myth, that seems to have caught hold of the imaginations of many of the reviewers of this book, that scientists at Eli Lilly deliberately set out to design a drug to selectively block serotonin reuptake with a view to treating depression more effectively. While it is probably the case that Eli Lilly did produce the first of what are now called the selective serotonin reuptake inhibitors (Footnote), they appear to have had little idea of what to do it once they had produced it. Depression was far from their minds. In contrast Astra although somewhat slower to synthesise a serotonin reuptake inhibitor appear to have had a much clearer idea of what they were doing and introduced zimelidine for the treatment of depression 5 years earlier than Prozac. Furthermore Prozac is not selective to serotonin reuptake inhibition in the sense that it also acts on a range of other neurotransmitters. There are other serotonin reuptake inhibitors currently on the market that are more specific inhibitors of serotonin reuptake and others that are more potent inhibitors of serotonin reuptake and arguably, therefore, the particular “cachet” that Prozac has may owe something to its effects on transmitters other than serotonin.
Kramer goes on to imply that our ability to selectively manipulate particular neurotransmitter systems has brought us to the brink of a cosmetic psychopharmacology revolution. In these days of designer babies and debate about the prospects of gene implantation, it was perhaps inevitable that some of the effects of compounds like Prozac on personality would be characterised in this way. This argument ignores the fact, however, that cosmetic psychopharmacology, as defined by the examples used in this book, was a flourishing industry in the 1940’s and 1950’s and that it subsequently vanished with the advent of newer compounds. A great number of people, particularly women, during this period, were taking amphetamines. These were at least as specific in their mode of action as Prozac and brought about comparable changes in the kinds of sub-clinical conditions that Kramer is concerned about.
Based in part on such observations, a comprehensive theory of personality, with a set of predictions as to the effects of drugs in particular individuals, was proposed by Eysenck in the late 1950’s. This theory has subsequently been developed by Gray and Zuckerman and biochemical flesh has been put on its psychological bones by Cloninger, van Praag and others. At present, the evidence in favour of the proposals these authors put forward is lacking but quite apart from the specific merits of any of these proposals, there is an an implicit assumpion common to all of them of a dimensional view of mental health/illness.
This is an issue that greatly exercises Peter Kramer as he takes the view that if we acquire the capacity to shift people along dimensions, then it’s not clear that there will be anything to stop us wanting to shift everyone toward a particular pole. Quite apart from the fact that there is a considerable over simplification involved in extrapolating from the effects of drugs at one end of a dimensional system to their effects on individuals at other points on a dimension, there is also the question that hasn’t been asked in this book as to why dimensional models of mental illness, which were extremely popular in the 1950s and 60s and indeed were implicit in all of psychodynamic theorising, should have been so comprehensively eclipsed by a categorical view of mental illness in the 1970s and 80s.
The answer to this must lie in part in the current structure of regulation within health care and the requirements of the insurance industry, particularly in the United States of America. So, however much a Peter Kramer may attempt to rally the masses to rise up with the cry that they have nothing to lose but their inhibitions, the politics of mental health are such that his call is unlikely to lead to any significant change until such time as some drug company produces a compound more specifically effective for more discrete sets of inhibited states than Prozac currently is.
Even then the prospects for the development of a psychopharmacologically based social engineering are guarded. Consider the case of the selective serotonin reuptake inhibitors and sex. It seems clear that these and other drugs active on the serotonin system have relatively specific effects on sexual functioning. There are also company sponsored studies which indicate, for example, that up to one third of men suffer from premature ejaculation problems, many of which might respond to Prozac or the other serotonin reuptake inhibitors for instance. But no company is at present pursuing such an indication – even though the market of people who might reliably respond to such interventions is likely to be considerably larger than that that might respond reliably to “cosmetic” interventions.
Unlike Heinrick Kramer’s volume which did not flinch from analysing the influence of those parties with an interest in mental health, where Peter Kramer’s book falls down is in its lack of critical edge. A number of reviewers have praised him for not drawing back from the big questions – the ethical issues (1,2,3). Clinical reviewers are likely to wonder what ethical problems there can be in treating depression (4,5). As a piece of discourse, however, a more interesting issue may be the rather whimsical way in which Kramer addresses the big questions. He has virtually nothing bad (or even critical) to say about anyone or any issue – the claims of a number of researchers are laid out and all are treated sympathetically, even when these are mutually contradictory.
In moving beyond clinical vignettes and taking on current research in this way, he departs from what is the latest genre – books written in “the Oliver Sack’s tradition” – to become something more of a pamphleteer. In this, he is following in the footsteps of the most famous or perhaps infamous medical pamphleteer, Julien Offray de La Mettrie. The parallels are close. One of La Mettrie’s most famous pamphlets was entitled Discours Sur le Bonheur. He also foresaw the day when we would be able medically to intervene effectively to shape behaviour, at which time medicine would supplant philosophy. La Mettrie’s pamphlets, however, were not whimsies – they were critical and acerbic. Vilified as the father of both modern atheism and totalitarianism, La Mettrie has sunk without trace. This presumably is a fate that Peter Kramer’s more whimsical style seeks to avoid and, as a consequence, we potentially face being recurrently bracketed between Kramers (Footnote].
Prozac was perhaps the fourth SSRI to be made and was the fifth to market – behind zimelidine, indalpine, fluvoxamine and citalopram.
Kramer did go on to produce Ordinarily Well in 2016. A review follows.