Biology 202

2006 Book Commentaries

On Serendip

Psychiatrist, Peter Kramer in his book, Listening to Prozac, offers profound insight into the topic of depression and thoroughly examines the implications of Prozac in both societal terms and in the terms of the concept of ones self. The book was written during a time when Prozac was relatively new on the market. His book largely discusses how the anti depressant, Prozac has revolutionized the power of psychopharmological medication. However; the book is about more then a very successful anti-depressant. Kramer describes how the medication has revealed to both therapist and patient that it does more than alleviate depression. Kramer uses the term "cosmetic psychopharmacology" to describe how Prozac and other medications can be used to make people feel "better than well" – making them better then he/she was before they had their depressive episode. He proposes that Prozac has the ability to "transform" one's behavior, as well as the concept of self. Perhaps, more fascinating than the answers the book provides about the drug, depression and the neurobiology of humans, are the challenging questions and problems it raises about these topics as well.

Listening to Prozac consists of combination of interesting case studies of the author's various patients and their reactions to Prozac, biological and psychopharmacological data, and philosophical reflections on these matters. Listening to Prozac gives the reader insight into the world of depression and how it is treated with anti depressants and psychotherapy, although the emphasis lies on anti depressants. Speculative themes throughout the book include transformation, cosmetic pharmacology, biological reductionism, the biogenic amine hypothesis, rejection sensitivity, harm avoidance, social inhibition, stress hormones, and learned helpnesses to name a few. Many of these themes are still considered minor variants of depression by psychologists. The book also contains interesting information about the history of the development of the various classes of anti-depressants, including the class of selective serotonin reuptake inhibitors that Prozac belongs to. The information is presented in a fairly nonmedicinal manner, one that is easily comprehendible by a very broad range of readers. The information incorporated throughout the book, includes how anti-depressants work, information about dopamine, serotonin, and how other neuro-transmitters work as well. The focus of the book however; lies in the case studies and philosophical exploration of the aforementioned. The case studies often have a tendency to keep you captivated and glued to the book in anticipation of the outcome. This is in large part attributed to whether the patient will become transformed with the usage of Prozac or not, and in what manner they will be transformed.

Many of the patients that Kramer discusses undergo this transformation, but what does this transformation consist of? This means that not only do they become "cured" of their depression, through mood elevation, but the medication seems to in certain cases have the ability to alter parts of an individual's personality. "Prozac seemed to give social confidence to the habitually timid, to make the sensitive brash, to lend the introvert the social skills of a salesman. It was transformative for patients, in the way an inspirational minister or high pressure group therapy can be."(14) Although, Kramer found that the changes in brain chemistry brought about by Prozac had a wide variety of effects, they were often transformed in this manner. He cites cases of mildly depressed patients who took the drug and not only felt better but underwent remarkable personality transformations. For example, a nurse has her failing marriage rescued when Prozac frees her from her obsessive concern with neatness and control. He had initially assumed that because most of the patients were only mildly depressed, such as in the case of the nurse, that Prozac would do nothing. Instead, what he observed both surprised and unsettled him. These transformations often extended to patients social, romantic, and business lives, as well as to their overall self-image. It often gave users greater feelings of self-worth and confidence, less sensitivity to social rejection, and even a greater willingness to take risks. It had the ability to affect multiple facets of an individuals behavior, including motivation, emotion, values, perceptions, sensitivity, and personality. He noted, the "cautious and inhibited" became "assertive and flexible" one patient "felt unencumbered, more vitally alive, less pessimistic" (52).

Kramer finds through experience with patients that the antidepressant Prozac is a powerful drug that alleviates the depression of most patients without significant side effects. Yet, Prozac was also affecting patient's personalities, which Kramer defines as "temperament as well as developed character" (95). It is the remarkable ability of Prozac to create personality changes that he finds disconcerting, as will the reader. Kramer unquestionably supports the use of medication to alleviate illness, but he does question using drugs to make a person feel "better than well." This induces Kramer and the reader to question whether the medicated or unmedicated version was the person's "real" self. It also raises the question of how much of our personality is biologically determined. Many believe that the conscious self or the I-function has a stronger influence on behavior than biology does because we tend to connect behavior with self-identity. Thus, by relying on a chemical to change biology and self without the knowledge or consent of the I-function, seems alarming and unnatural.

What then is the essence of self and personhood and what are the philosophical implications of using drugs to alter personality? The book raises these questions but does not necessarily provide answers to this. Kramer's unequivocal endorsement of Prozac for the treatment of depression and the questions he raises about the use of drugs for mood alteration are quite controversial The controversy that is raised, previously discussed, of which is the "true" reflection of a person remains to be answered. Do the transformations Prozac induces, reflect an unnatural idealized social norm or are they unveiling a healthy individual trapped in an unnatural state, that not of their "real" selves. Kramer asserts that "Patients believed that Prozac revealed what in them was biologically determined and what merely experiential."(170). Thus, "medication somehow removed a false self and replaced it with a true one?" (19). Kramer in accordance with this speculates that these changes represented the emergence of ones true personality and that their true personality was masked for most their lives by a depressive illness. Many of his patients upon ending taking the drug would say, "I'm not myself again" (10). For these individuals suffering from mild depression or anxiety, the medicated self ironically became the "real" self despite being in an altered state. The medication in this manner has the potential of becoming and defining a new self based entirely on the pill's neural actions while eliminating the old self as false and somehow untrue. (172)

The whole concept of self also brings to concern of whether we are willing to allow medications to tell us how we are constituted. Can who are we be altered by medication? "Prozac has the power," Kramer asserts "to transform the whole person—illness and temperament...."(247) This then raises the question "How is it that taking a capsule for depression can so alter a person's sense of self?"(332) Perhaps, Prozac has its own inherent characteristics and personality and that this personality contained in a pill is just replacing the persons "real" personality. Dr. Kramer himself notes that Prozac has "characteristics" and a "personality" which affect the human brain (257). Or perhaps it is really the opposite and we are innately all born with similar temperaments that do not include anxiety, compulsiveness, or sensitivity. Perhaps, personal experience in some manner damages our temperament, and Prozac can restore us to our undamaged self.

Throughout the book, Kramer struggles to put some of his mildly, or hardly depressed patients into the correct diagnostic category, such as those who experience hypersensitivity, or OCD. He however; seems to be aware of the danger in this. He seems concerned that psychiatrists might mask the difficulty posed by the diagnosis of these patients by defining less severe mental states as illness. (106). It seems as though the logic Kramer wants to avoid is: if it responds to an antidepressant, then it is depression. In the book he states that we have used medication response to infer the cause of the disease since the last half of the twentieth century (107), does this mean that medication is able to give insight into the constituion of ourselves?

For those aforementioned, such as those with OCD, the question naturally arises: if Prozac is not treating depression in these patients, what, if anything, is it "treating"? Is it treating unhappiness, angst, or something spiritual? Maybe it is acting as a remedy for emptiness, confusion, anxiety, or a lack of direction. Can this pill really cure all our discontents? Kramer hypothesized that Prozac is affecting certain areas of the brain concerned with "feelings of abandonment." (235) That is, it is not simply a matter of neurotransmitter and other chemical involvement but a matter of a rather malleable material, or brain area, through which the emergence of something deeper occurs.

Prozac's ability to cause such a drastic change on a biological level causes much concern because the change does not need to be processed cognitively or even consciously through the I-function. This fact therefore challenges "the model of healing through cognitive powers" (219), due entirely to its biologic effectiveness. Personalities through the use of Prozac can be altered instantly, and do not have to be painfully acquired through insight and hard practice. The power of biology here can is seen to be exerted over a large spectrum of human behavior. Prozac is able to do what only psychotherapy could have done in the past. It has the potential to alter a particular element of personality. For example, it can eliminate the specific trait of rejection sensitivity. It is quite a feat for just a pill to sculpt personality trait by trait.
However; in note of all this, does this mean psychotherapy is not needed anymore? This is not so. Prozac does not eliminate the need for psychotherapy. Dr. Kramer believes that for the treatment of minor depression and anxiety, psychotherapy is best. Medication can interfere with the patient's introspection, analysis, and understanding. He finds the results of Prozac much better if the patient has first undergone extensive psychotherapy and has insights of the origin of his symptoms. He believes it prepares the patient to be well and that Prozac works best on those whose conflicts have been resolved but who still have symptoms. (278) This means of thinking must be kept in mind as it is not hard to become blind sighted by the biological aspects of treatment. One patient for example, even on Prozac felt a great sense of urgency; however upon stepping back from the biological aspect of a possible side effect of the drug, Kramer observed that the urgency was not a side effect, but rather a psychological longing of her deceased mother.

Although Prozac seems to induce alarming effects, it does not mean that it should not be used. Kramer advocates its use. He notes patients seem to gain the insight and perspective that years of psychotherapy would aspire to achieve, but in a fraction of the time. He also claims that Prozac frequently seems to push patients toward a normal or near-normal condition, sometimes called by psychiatrists "hyperthymia," (27). He feels that, many patients including some who may never have had a diagnosable mental illness-are better able to explore both their past and their current circumstances while they are taking Prozac. To some medication constitutes help in recovery from childhood trauma or protection from the "threat of terrible decompensation.." (256) He feels the drug seems to aid rather than inhibit the struggle to locate the self.
Also something that must be noted is that although the case studies described narrate a significant change in functioning of individuals—transformation is not all that common. Not all patients respond in this manner, others merely recover from depression, as you would expect of an anti depressant. Medication after all, is supposed to heal not transform personality, right? This remains debatable. However, Kramer also notes that while certain patients seemed to be handicapped in aspects of their personality most of what we would call their personality persisted in a recognizable manner. (174)

Listening to Prozac raises many questions. Among these questions is whether it is ethical to prescribe a drug that increases things such as a person's self-confidence, resilience, and energy level without any ill effect, even when there is no underlying manifestation of illness? In this effect it may be possible for the medication to rob us of what is uniquely human such as characteristics, such as anxiety, guilt, shame, grief, self-consciousness. This raises the question of whether cosmetic psychopharmological medication will eventually convince us that these affects are not uniquely human. Are we not losing sight of something about ourselves that should be included in our conception of self, when we see things like guilt as something to be treated, rather then seeing them as part of the human condition? Prozac may eliminate illness, but in so doing it may also be eliminating what is a perfectly sensible response to life's circumstances. More so, the overuse of Prozac may mean that perhaps a sickness of the culture at large exists. A culture that is essentially seeking to anesthetize itself from the inherent pain of human existence. This does not just include cosmetic psychopharmacology; this is done on a regular basis through alcohol, drugs or gambling etc.

Prozac in this manner and by nature of what it is has the potential to move us in a dehumanizing direction. In people with minimal depression, Prozac acts as a type of social un-inhibitor, maybe even analogous to the equivalence of having a few drinks and becoming more sociable. However; just because our society favors social forwardness, does not give science the permission to change people's biology so they can derive happiness and pleasure in fulfilling a cultural ideals, or does it? Prozac has the potential of creating a homogeneous society with modified and standardized behaviors even despite a hereditary of biologic difference among people that Kramer notes. "All men are created equal in our political and moral ideal, but they are created biologically heterogeneous in temperament" (298) However, in contrast to this one might believe that curing minor depression induced by societies ideals elicits no substantial harm. It in fact alleviates the pain of some individuals. In argument of this, if society already has a narrow view of the ideal personality, wouldn't it make it more likely that we would diminish the open mindedness of personalities further? Thus eliciting the threat of a homogenous society and eliminating certain biological temperaments innate to human beings. Also, what does it signify that so many people who have shaped our manner of thought including philosophers, novelists, poets were depressed? As a culture we will increasingly face this dilemma of whether to broaden the definition of illness or to agree with the fact that treatments are being used to influence normal mental states

Listening to Prozac not only seems to reveal to patients what they believe to be their true selves, but for psychiatrists, such as Kramer seems to alter ideas about the human condition as well. For example, the author changed his ideas about basic personality theory as a result of listening to patient experiences with Prozac. He now accepts that many behaviors, which were believed to be inborn are actually "neurotic." Thus, is human individuality in danger of being eliminated by biotechnology, psychological reductionism, and behavior modification? It is fascinating and unnerving to think that a modern medication such as Prozac has the potential to allow a person to experience, on a stable and continuous basis, the feelings of someone with a different temperament and history.

The use of Prozac has shown that medication that induces a neurological change in one has the ability to transform a person's behavior, and conception of self. This thus, provides evidence that brain does indeed equal behavior. A portion of the brain, not part of the I-function, is inducing individuals to behave in a certain manner, and conceptualize themselves differently. Prozac contradicts the discussion of chemicals influencing the brain but not determining patterns of behavior. In this case the chemical makeup of Prozac is in fact determining the behavior of patients. There does however, exist, an element of unpredictability in the generation of the patterns even upon taking Prozac. It may not work for one individual as it does for another. This is evident in the fact that not all patients undergo transformation. Prozac also seem to oppose the idea that drugs are not capable of targeting the individual details of particular patterns, as evidenced by examples aforementioned; this is not always the case. It does not always influence patterns at fine scales, but can have the potential to do so.

Listening to Prozac brings to attention that what we often value, that of human conscious control, may be secondary to our biologic determination. We may just be largely a product of genetics. Kramer's book is a thoughtful, at times fragmented and inconclusive reflection on cosmetic psychopharmacology. Concepts such as mood personality and self become unstable and fascinating. Yet while Kramer ultimately defends cosmetic psychopharmacology, he does not pretend to have answers. Instead he suggests possibilities, and frequently offers opinions, but remains very candid about his own discomfort with the idea of cosmetic psychopharmacology. It seems his aim is more to explore what the effects of Prozac mean for larger philosophical questions about the self and how we come to be who we are.

References
1) Kramer, Peter M.D. Listening to Prozac. New York: Viking, 1993.


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