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.
Copyright © Data Based Medicine Americas Ltd.
Always good to learn a bit more; psychiatrists today, are not particularly good at philosophy or humanities and one wonders if some of them, indeed, might have been better off becoming clergymen such is the lack of thought when many push their ill-assorted opinions on to others –
In 1734, he went on to study under Hermann Boerhaave, a renowned physician who, similarly, had originally intended on becoming a clergyman.
he made observations on himself with reference to the action of quickened blood circulation upon thought, which led him to the conclusion that mental processes were to be accounted for as the effects of organic changes in the brain and nervous system. This conclusion he worked out in his earliest philosophical work,
La Mettrie cites how the body and soul are one in sleep, how humans must nourish their bodies, and the intense effects of drugs on both the body and the soul, or mind, noting that “diverse states of the soul are always correlated with those of the body.”
Then Kramer asks this question: What would it feel like to live in a world where practically no one was normal? Where few people are free from “psychological defect?” What if normalcy was a mere myth? He ends the article with this poignant paragraph:
We are used to the concept of medical shortcomings; we face disappointing realizations—that our triglyceride levels and our stress tolerance are not what we would wish. Normality may be a myth we have allowed ourselves to enjoy for decades, sacrificed now to the increasing recognition of differences. The awareness that we all bear flaw is humbling. But it could lead us to a new sense of inclusiveness and tolerance, recognition that imperfection is the condition of every life.
Using the word ‘lofty’ not lightly is perhaps where psychiatry goes often wrong – when it becomes almost a religion hiding behind modern psychiatric folklore and fantasies …
Listening to Prozac – and the reviews of it 25 years ago – are truly a Blast from the Past. Oh yeah—I remember what the big ethical dilemmas were supposed to be, back then:
What will it do to society, when happiness can be found in a pill? Will we stop struggling to change unjust systems? And since pill-takers will be clearly happier and more effective, will we really have any choice if we want to compete? I also remember friends who actually envied me my diagnosis of Major Depressive Disorder (which back then was not so pathetically easy to get) because it meant I’d be allowed to take the magic Prozac, whereas they wouldn’t qualify … so unfair!
That was before we all got so familiar with Prozac, and its SSRI cousins, and realized they were not so magical after all.
Now about 11% of Americans over age 12 are on these pills – and about 20% of working-age women. If Prozac really made you Better than Well, you’d think the men would catch up if not dominate the market. But no, it’s more like Uncomfortably Numb. Most people are on them for years, not because they love that Prozac Feeling, but because they feel so horrible when they try to stop.
Perhaps the best bit of black humor in last week’s review was the bit about Prozac enabling us to “thrive at work, at home and in the bedroom.” Oh, really? Well, SSRI’s may enable some people to trudge back to work – and the less your job requires enthusiasm or devotion the more useful they may be. At home? Not so much. And in the bedroom? Well I think we all realize what a sick joke that is …
Well, I was merely a young lad when these ‘ethical dilemmas’ seem to have been debated. A high functioning young man about to spice up a bedroom or two. (*winkyface*)
But the onset of the Uncomfortable Numbness didn’t just remove the very idea of joining anyones bedroom, not on any level, not even in my fantasies.
‘Twosome’ became the idea of being one more than the one I had trouble getting through the day with.
To trudge back to work, an impossibility, when your ‘inner drive’ just isn’t there anymore. I think David Healy talked about ‘anhedonia’ somewhere, when even the simplest of tasks becomes monumental.
And now to realize I’ve become (on a tiny scale) a part of the outcome of their ‘dilemma’, it’s scary to know there were critics back then too.
You see, I thought at dilemmas, one should always chose the side with the least damage. A simple cost-benefit ratio. Like in any psychological dilemma, should you save one person, if you know it hurts two others, and so on.
I’m as educated as a brick wall, but I know that if you chose one side of a dilemma, and it turns out to hurt millions more than it ‘saves’, then you should write another book saying you were wrong.
Psychoanalysts did to some extent think of themselves as the creme de la creme but realised they were losing the fight for survival in the NHS – (there was a confrence in the 90’s ‘Adaption or Extinction ‘ by UKCP but analytic orgs seem to have taken on the message. They needed to prove psychoanalysis to be a scientific enterprise which has led some to adapting and a lot of morphing into other areas particularly in Child Development. So children now are having their brains imaged by their researchers to find how much their environment is affecting their brain. This includes the style of parenting which relies on attachment theory linked to psychoanalysis linked to neuropsychiatry. At UCL and Yale there are what’s called Child Labs conducting research.As ever the families and children come from the most disadvantaged backgrounds and are being researched by people who come from vastly more advantaged backgrounds -strangely like the Victorian voyeurs who collected records on ‘the poor’ in UK . and decided what should be done with or to them.
One of the most loathed manuals is the psychiatric diagnostic manual .Instead of listening to the anger about that from people on the receiving end the alliance of psychodynamic organisations produced their own manual – The Psychodynamic Diagnostic manual 2nd edition 2006 on Amazon for a free read (and elsewhere ) my comment to it was undermined by a suggestion that I hadn’t read the manual – not all of it – who would want to even practitioners admit they don’t but it’s worth a read through to see how fellow human beings have such a fragmented view of ‘others’. The 1st edition was easier to read but no better.
My comment to it on amazon 2nd Aug 2017 was ‘ The usual culprits iin UK have been involved in drawing up this shockingly dehumanising cartload of diagnoses and labels .To claim they are producing this book with the aim of highlighting that people are more than their diagnosis just denies material that is in the book It has done a massive disservice to psychoanaylisis at a time when there is so much concern about attaching labels to persons in the psychiatric world This group has just aped the psychiatric diagnosis manual in an attempt to make psychoanalysis more scientific to it’s critics and critically funders and politicians.It is shameful to subject clients to this dehumanising checklist of ever more refined desriptors as if human beings could ever be understood by another by using a manual or a computer . Someone called Robbie Jay put it better than me but his final sentence was ; Jan 2018 The decline and fall of psychodynamic thought . How psychiatry defeated the last challenger – a tip of the hat to those million dollar pharma companies proving again that money can buy anything including the last psychodynamic thinkers’.
The Anna Freud Centre morphed from a child guidance centre and has morphed recently into the Kantor andAnna Freud Centre of Excellence with a glossy new building in London -funded by millions ( named after their relative) It is a private charity The Pears Foundation run by three millionaire brothers. They control which projects get funded according to their own stated ethos of civic and family values. Peter Fonagay the CEO and colleagues have massive influence through contacts and networks which are unavailable to others , amounts of money and freedom to fund projects which conform to the funders’ ethos but it is not spread evenly and promotes their own self interests in spreading projects of social control – even to funding a private school and social housing. It’s not good to for society to be dependant on this kind of set up surely. To be fair there are many who have used their services who express their gratitude – one good thing is they seem not to be drug orientated but where is all the brain imaging leading to..?
Have spent a miserable few hours reading some references on the net to the Malleus Maleficarum, The Hammer of the Witches. (I learn loads of stuff by reading D H blog, thank you). As I’m very suspicious about the use of manuals to assess and diagnose mental health , what resonates is how this was happening, maybe began, in the 15C with the hunt for witches -‘the main purpose of the book was to challenge all arguments against the existence of withcraft and to instruct magistrates using casebooks ,how to identify, interrogate, and convict witches. Kramer travelled around delving into records. Some sites state that the cruelty and persecution of the mainly women was endorsed by the pope. So many parellels to the psychiatric /medical/political/pharma establishment. If the women denied any of the labels attached to them – it was used as further proof against them.
My suspicious mind has doubts about the empire building by the Anna Freud-Kantor Centre of Excellence (even the cringy self important name jars). It’s too big brother and expanding all the time: – Peter Fonagay CEO claims ‘1 in 8 , 5-9 year old children in England have at least one mental disorder according to standardised diagnostic criteria . (Yet another manual drawn up by those with self interests at stake). This equates to 1.25 million children and young people. They claim that ‘Half of all life time cases of mental disorders excluding dementia begin by age 14yrs and three quarters by the age of 24yrs’. How many people have had their records delved into or been ‘assesed’ in order to come up with these statistics? Or are they little more than guesses to support the massive expansion of observation and control they have already began by projects in schools and homes throughout England. And by the collection of family records and brain scans. If this comes over just as a rant – it’s not just meant to apply to the Kantor center of excellence it’s also happening in the USA with the same group developing projects in schools and homes and ‘baby labs’, Kramer3 might be proposing drugging children from birth if their brains don’t conform to a standardised diagnostic manual or removal to a centre where some paragon of ‘carer’ can give them better parenting according to directions from a manual. A psychoanalyst described by P F as one of the most profound thinkers of today claims that children can be identified as users of facebook by a scan of their brain. Perhaps more practitioners should have their own brains scanned before they start working to modify other people’s not just lives but personalities. Aplogies it became a bit of a rant.
Susanne, I shall continue your ‘rant’ as you called it 9not a rant at all in my book, just a few home truths!). What infuriates me is the fact that we’re obsessed with ‘perfection’. The perfection being the warped (again, in my book!) ideals of a certain class of ‘thinkers’. Wherever we turn, we are bombarded with information of how to make ourselves better than good. Adverts have always tended to treat us that way but now it has gone way beyond the ‘best toothpaste’ or ‘most nourishing breakfast cereal’, it appears, time after time, in all areas of our lives. Is it any wonder that we are such an unhappy bunch? (that, too, I guess, being some ‘think tank’ s latest finding?
We know that parents have always seen their offspring as being smarter than the average child – that is the nature of parental gloss I guess! Now, the education systems are pandering to that very idea – that everyone’s child must be ‘better than good’ and going to a school that holds a record of being ‘better than excellent’. Where will it all end?
To my mind, the more we push the ceiling of perfection the greater the number that will fall by the wayside. In education,this craving for perfection helps no one except the ones who set the standards. If it were of value, then, surely, by now, every school pupil and teacher would be part of a brilliant institution. A craving for ‘perfection’ causes serious unhappiness. Change it to ‘being the best that you can be’ means an acceptance of our failings as well as celebrating our successes – a far healthier situation all round, doing away with the craving for ‘happy pills’ in all age groups.
As I mentioned in my response to Johanna above, I was very young when this book came out, and still had about 6-8 years until I was prescribed the pill. But.
The article above reminded me of how, among average people like myself, still talked about antidepressants as ‘happy pills’ or in a very ‘inert’ way. A positive way. Almost as if marketers had managed to put SSRI’s in our vocabulary long before we needed it ourselves.
Most likely they had. In newspapers, TV and movies, perhaps even on the radio back then. Someone had cleverly and deliberatly lowered our guard for these pills.
I took Seroxat without questioning it.
But later on, about 3 years into SSRI, I was prescribed Valium, and this was a totally different story. I was terrified of Valium, I was terrified that I was in need of it. Evidently something made me cautious about Valium the way I should have been towards Seroxat too.
I don’t want to bear a giant tinfoil hat here, but I suspect someone must’ve made us lower our guard, or most of us would be very weary about taking drugs that directly acts on our brain. Good science or bad science, fiddling with the brain is what we are told not to do when talking about illicit drugs.
Just to bring up the question, even unanswered, if we all should eat the pill, lowered our guard. It gives the illusion that some scientist seriously thinks we should all eat them.
Job done, who in their right mind would question a drug that we all might benefit from?