Book Reviews - Winter 1993

LISTENING TO PROZAC: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self
Peter D. Kramer
Viking Penguin: New York, 1993. 409 pp., $23.00 (cloth).

William Greenberg

YOU'RE a hard-working, reasonably successful woman in your line of work, but feel socially inadequate, unhappy, and, stuck in an unsatisfying relationship with a married man, now feel significantly depressed. Psychotherapy can't seem to pull you out, but the antidepressant medication Prozac does. Taking Prozac, however, you also become what you never were before—outgoing, attractive to men, popular, less needy and self-defeating in relationships, and assertive when necessary at work. Discontinuing Prozac months later, the inhibitions, self-doubts, indecisiveness, and lowered self-esteem that were your lifelong personality return. You ironically observe to your psychiatrist, Peter Kramer: "I'm not myself anymore."

Do you ask for the Prozac again? Would you feel something impure about doing so, relying on a pharmacologic crutch when staunch effort, psychotherapeutic growth, and/or religious practice and revelation were instead appropriate? Would you feel you would just be "drugging yourself"? Another woman does offer that she feels ". . . as if I had been in a drugged state all those years and now I am clearheaded." But she is telling us she feels clearheaded only on the Prozac. What is going on here?

Psychiatrists have often treated individuals with serious psychiatric conditions, such as manic-depression, acute psychosis, and major depressive episodes, helping those unable to make progress in psychotherapy, or even function adequately, until they were treated with medication. Dr. Kramer has been moved by new observations of Prozac's positive effects on individuals for whom ten years ago most psychiatrists would never have even thought of prescribing medication. Chronically unhappy but not suffering from major depressive episodes, such people would be told: "Your problems are characterological and pills can't help; you need long-term psychotherapy." Our real hopes for such patients, whom we often diagnosed with the label "depressive neurosis," were often modest: Freud aspired that psychoanalysts should transmute such individuals' misery "into common unhappiness." Now, however, we view chronic mild depressions (even if remembered as present from early childhood) as related to other types of depression, and often find such conditions responsive to antidepressants. But are we treating a clear psychiatric disorder or merely personality traits or temperament? Are we indulging in something as cosmetic and artificial as a "nose job"?

Dr. Kramer and some of his patients worry about such a trend. To be sure, this entails drawing a somewhat arbitrary line. We routinely treat other physiological deficiencies with medications (insulin for the diabetic, Synthroid for the hypothyroid, estrogen for the postmenopausal woman), we adorn our appearance with attractive clothing and jewelry and hairdos, change our smells with perfumes, engage in muscle-building exercise (sometimes by anabolic steroids or human growth hormone). We legally enhance our thinking ability or mitigate our anxiety level with the potent pharmacologic agents caffeine, alcohol, and nicotine (and may use amphetamines, cocaine, marijuana, LSD, MDA, etc.). Is there duplicity here? Or is there something less "natural," perhaps, in a manufactured pill? Our unease must stem in part from the intimate association we make between our personality and our cherished sense of Self. But what if we forget the Self?

My approach to the use of anti-depressant medications, like Dr. Kramer's, has evolved over the last decade. Trained more in the culture of psychotherapy, I and my colleagues were initially cautious and uneasy when some of those we treated promptly relapsed whenever their medication was stopped, or when we treated mild depression in those just wishing psychotherapy. I now appreciate the demonstrated wider scope of these medications' potential value, representing an important response to treatable human misery. Like Dr. Kramer, I have found that some of my responding patients have had only what appeared to be problematic personality traits, such as over sensitivity to perceived personal rejection. Dr. Kramer has an articulate voice, and openly and accurately conveys the usually unspoken monologue of a clinician thoughtfully practicing his profession, understanding his patient as an individual, applying the art of psychotherapy, the science of medical psychopharmacology, and relevant ethics. His historical digressions are effectively engaging. He provides a provocative, interesting read.

This book also has faults: its chapters form a collection of case studies and thematic essays not carefully enough woven together to avoid redundancy in the later chapters. Its audience is unclear. It appears to be targeted for the general public (and has been an impressive seller on The New York Times nonfiction list), but it has more than sixty pages of scholarly end notes (unreferenced in the text) and a detailed index. Discursive forays into diagnostic issues, psychopharmacology, psychobiology, sociology, animal ethology, and philosophical ethics may be more than some of the intended readership wish to plow through. Dr. Kramer unreasonably slights the classic antidepressant. The book focuses almost exclusively on Prozac (a drug whose popularity has attracted both idealization and notoriety in its brief career), although similar drugs deserve adequate mention (the author denies a financial interest in Eli Lilly, Prozac's manufacturer). Moreover, it promotes the impression that these personality "makeovers" are common, but most of our Prozac patients do not undergo such transformations.

What of the future? Will we have "Better Living Through Chemistry"? Kramer can not resist optimism. In "listening" to Prozac he feels the transformed patient may come to recognize new possibilities: ". . . leaving the self light and unencumbered, she may arrive at . . . new understandings about. . . her (human) nature." I'm reminded of such hopes in a generation first encountering LSD—the results then depended very much on the setting and who was taking the drug, and it was best to have a guide. This comparison is unfair—among other issues Prozac is much less risky, but if you feel such medication may help you, for best results make good use of a guide. This book may serve as an introduction.

William Greenberg is Chief Psychiatrist at Bergen Pines County Hospital in Paramus, New Jersey.


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