I have recently been working my way through Peter Kramer’s 1993 classic, Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. It has turned out to be quite different than I expected. I had run into the title in several histories of psychiatry (e.g., Anne Harrington’s Mind Fixers [2020]) and was generally under the—mistaken, I now realize—impression that the book fit squarely into the biologically-reductionist hype machine that surrounded the introduction of drugs like Prozac in the late 1980s and early 1990s. These days, it is quite common to look back on the early 1990s as a time of irrationally exuberant optimism about psychiatric medications, a kind of period of neo-Hippocratic humoral theory about serotonin (Kramer himself, somewhat ironically, I think, refers to serotonin and norepinephrine as “neurohumors”), a return of the repressed biological dimension to psychiatry and society writ large—when the Human Genome Project seemed to hold out the allure of quick fixes and even quicker explanations, and when one could still chalk depression up to a “chemical imbalance in the brain” with a straight face.
These
currents weighed heavily on me as an adolescent and young adult, and I formed
myself largely in opposition to them. A strong Romantic, anti-scientific and
pro-humanistic current ran through a lot of my own thinking until I was in my
late 20s. I had read Stephen J. Gould’s Mismeasure of Man in high
school, and then, in college and grad school, I was drawn to phenomenology,
existentialism, and German Idealism, each of which, in its own way, is opposed
to the idea that we are just our genes or our “neurohumors.” In 2024, though,
the biological reductionism (a term that deserves to be interrogated further)
of the 1990s has been long dead or at least has been in its death its death
throes for a while. The old hope that a “gene for” each of the DSM disorders
would be found now seems dismally naïve, even as increasingly sophisticated
genome-wide association studies and other methods of genetic research have been
pioneered. The efficacy of SSRIs, the class to which Prozac belongs, has been
much disputed in warring meta-analyses, and difficult-to-parse data about
placebo efficacy in clinical trials have emerged. In the biological reductionist
camp, the DSM itself has come under fire, with the NIMH attempting to replace
it in research at least with an alternative system. Drug makers have largely withdrawn
from funding new psychiatric medications. (All of these claims deserve
citations beyond what I care to dig up right now from my reading notes, but two
sources that cover a great deal of what I say here are the aforementioned book
by Harrington and sociologist-biologist Nikolas Rose’s Our Psychiatric
Future, 2019.)
In short,
I was worried that Kramer would come across as terribly dated. I was wrong. Listening
to Prozac is not a partisan screed in favor of biological reductionism
about mental disorders. It is, rather, an essay, in the old-fashioned sense of
the world—an exploration, a problematization, less a book with a thesis than a
trying-on of different ideas and questions opened up by the clinical practice
of prescribing what Kramer prefers to call thymoleptics, rather than
anti-depressants, after the Greek thumos, for spirit or emotions (p. 176).
(Although Kramer does not mention it, this is the word associated with the “spirited”
class in Plato’s tripartite division of the city and the soul—the enforcers
sitting between the guardian class and everyone else.) And Kramer is not simply
writing about Prozac. As regards medication, this is as much a book about the
first two classes of so-called anti-depressants, monoamine oxidase inhibitors
(MAOIs), such as phenelzine (Nardil), or the tricyclics or TCAs, such as imipramine
or clomipramine (Anafranil). It is also a book about lithium, the discovery of
the efficacy of anticonvulsants like carbamazepine for mood disorders, and
amphetamines.
I see
three main themes in the book. First, Kramer is writing at a kind of point of
inflection, and he is aware of it. The 1980s had seen something of a civil war
in American psychiatry between the dominance of psychoanalysis—which, most
commentators on the subject note, had never achieved such promise in European
psychiatry—and biological approaches claiming the mantel of Kraepelin. The war
is the subtext for some of the stranger decisions in DSM-III, as Nasser Ghaemi has
argued in the case of the construct of major depressive disorder. It was typified
in the lawsuit Osheroff v. Chestnut Lodge, in which the depressed nephrologist
Dr. Ray Osheroff sued the prestigious Chestnut Lodge psychoanalytic clinic for
not prescribing him medications; the warring factions lined up as expert
witnesses on either side of the case. (For a discussion of the importance of
this case, see this, this, and above all Rachel Aviv’s
new book Strangers to Ourselves.) Kramer does not mention the Osheroff
case, but he is reflective about the turn from a primarily psychoanalytic
understanding of mental illness and personality to the new biological
approaches drawn from psychopharmacology, genetics, animal studies, and
sociobiology. He resists any easy answers. In many ways, he functions less here
as a scientist-practitioner and more as a cultural critic taking the pulse of
the moment and noticing the broader philosophical and sociological implications
of this paradigm shift.
Second,
Kramer is concerned to argue—this is perhaps the only definite thesis in the
book—that Prozac and other medications do a lot more than they are advertised
to do. He is particularly interested in the personality changes he observes
from patients to whom he prescribes Prozac, as well as the role of Prozac in
treating a variety of conditions that are in no way obviously derivative of
major depression: he finds it leads to increased confidence, reduced
compulsiveness, reduced rejection-sensitivity, reduced proneness to panic
attacks, greater resilience in the face of stress, reduced shyness, improved
self-esteem, improvements in the ability to experience pleasure (the problem of
anhedonia), more organized thinking, and the treatment of a whole host of
chronic low-grade matters of temperament. The evidence for efficacy is stronger
in some areas than others; on the whole Kramer rarely rises to the sort of evidentiary
standard that we expect today from another revolution that was beginning around
this time, evidence-based medicine, with its emphasis on randomized controlled
trials, systematic reviews, and meta-analyses. But the larger claim seems
correct to me, namely, that the SSRIs, and also, to a certain degree, the TCAs
and the MAOIs, produce a variety of different changes, some of which are deeply
uncomfortable since they challenge existing ideas about the boundary between the
normal and the pathological and about the appropriate limits of psychiatric
intervention. These challenges are perhaps typified in the problem of what
Kramer calls “cosmetic psychopharmacology,” or the possibility of prescribing
these medications not in order to treat illness but rather to create desired
personality modifications, to help someone achieve a “better-than-well” status (pp.
x, xv, xvi, 15,97, 184, 246-249). Cosmetic psychopharm might have shifted to
psychedelics, MDMA, and microdosing, the but idea, the practice, and the larger
existential concerns they traffick are all still very much with us.
It is, however, the third main current that most interests me in this book. This is the current that comes closest to the sort of thesis one finds in science and technology studies. Kramer shows, more than he argues, that how we think about the boundary between well and ill, normal and pathological, and how we think about the nature of clinical entities themselves depends a great deal on the technical means of intervention available to us. Stated in its extreme form, this would be a kind constructivism-nominalism according which what makes something a type of mental illness, as opposed, say, to a character oddity, is the existing technological armature for modifying it. It's not disorder until we can drug it. And, in turn, what drives our search for such a technological armature is our own shifting set of cultural concerns, so that shyness, inhibition, and sensitivity to rejection, for example, only become pathological under definite social circumstances. Kramer does not actually subscribe to quite such an extreme sociologism, but he makes us feel the weight of such a position, the difficulty of avoiding such conclusions. He makes us feel the force of a claim that used to be quite commonplace in the 1960s and 1970s but seems to have largely disappeared in recent decades: that mental health professionals are, in no small part, in the business of helping people who struggle to conform to social norms conform better. We are left not so much to agree with this conclusion as to struggle with the messiness of it all, the unclarity regarding the telos of clinical practice.
There is a deep sense of historicity and contingency in this book, perhaps most typified in the discussion of Donald Klein’s concept of rejection-sensitivity and his diagnostic category of hysteroid dysphoria in Chapter 4 (pp. 71-97). One feels how things could have been otherwise if Klein had had SSRIs at his disposal when he began his research in the 1960s. One feels how contingent and arbitrary the diagnostic categories of DSM-III and following were, how contingent and arbitrary it was that we came to see SSRIs primarily as anti-depressants. And, to his credit, Kramer recognizes that the role of technology in shaping the boundaries of the normal and the pathological does not just fall to medications. In his chapter on self-esteem, he notes that therapy, too, is a type of technology, also capable of cutting up nature, joints be damned.
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