Scientific progress

The 30th anniversary of Peter Kramer’s classic ‘Listening to Prozac’ brings a new edition.

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For those who remember Peter Kramer’s landmark 1993 book “Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self,” it is hard to believe that it burst on the scene 30 years ago. It became a national and international bestseller, which is not surprising, as it brings forth so much interesting information and so many thought-provoking questions.

Kramer’s new edition, with an updated introduction and afterword, examines, among other things, the progress in the scientific studies as well as trends in the use and public understanding of antidepressants, and also looks at potential breakthroughs in the treatment of depression. Reading it helps us look at both what is the same and what has changed about the implications for medical practice, giving us incisive perspectives on antidepressants, mood disorders, and our understanding of the self.

In his original introduction, Kramer writes, “By now, not yet five years after it was introduced, 8 million people have taken Prozac.” We learn that the drug works by changing brain chemistry. But while Kramer discusses the antidepressant as a treatment for depression and anxiety, the true focus of the book, as the title suggests, is the questions the drug raises in examining what constitutes the self. “My concern has been with a subset of these millions: fairly healthy people who show dramatic good responses to Prozac, people who are not so much cured of illnesses as transformed.”

Kramer uses case studies and the evolution of relevant research when exploring the impact of Prozac on different mood disorders that affected clients, with chapters addressing compulsion, sensitivity, stress, risk, low self-esteem, inhibition of pleasure, and sluggishness of thought.

In treating patients with these issues, Kramer noticed that Prozac seemed to change personality traits that patients found onerous, increasing their confidence and muting social anxiety, turning shy, sensitive people into social beings, as well as improving memory, energy, and work performance. Many expressed after what appeared to be this transformation that they felt “better than well,” significantly impacting their view of themselves. Kramer writes, “They experienced something like a change in temperament. To some patients, the shift away from obsessing and toward assertiveness was so marked that it seemed to contain news about how they were constituted. I set out to discover and then explain how medication engineered to alleviate depression might reset personality traits as well.” The implications are profound as he asks, Are these changes caused by a drug revealing or creating what the patient considers their true self?

Kramer writes about the profound impact of his observations: “Spending time with patients who responded to Prozac had transformed my views about what makes people the way they are. I had come to see inborn, biologically determined temperament where before, I had seen slowly acquired, history-laden character. I formed new beliefs about how self-esteem is maintained, how ‘sensitivity’ functions in interpersonal relationships, and how social skills are employed.”

The implications for psychiatry and psychology are significant: “It is now sometimes possible to use medication to do what once only psychotherapy did — to reach into a person and alter a particular element of personality. In deciding whether to do so, the psychopharmacologist must rely on skills we ordinarily associate with psychotherapy … It is one thing for a doctor to be able to transform a patient with medication, quite another for the doctor to be able to sculpt the patient’s personality trait.”

Correspondingly, Kramer makes the salient point that these traits belong to a socially assertive personality, which is valued in contemporary society and, thus, raises philosophical and ethical questions about the impact and application of biological treatment. He writes, “Once we have seen the joy on patients’ faces, we can only be grateful for the availability of more powerful and specific medication. But the awareness that what we are altering is a personal style that might have succeeded in a different, and not especially distant, culture may make us wonder whether we are using medication in the service of conformity to societal values.”

In the new afterword, Kramer addresses cutting-edge research about important changes in psychiatric theories regarding the nature of depression and depression treatment. Interestingly, when I asked Kramer in a recent email what he would like readers to come away with from this new edition, he said, “I love my profession, and especially now when it’s so often under attack, I would like for readers to gain an appreciation for its difficulties and complexities — and the level of effort that clinicians apply in an attempt to understand patients and their ailments. Similarly, for the research. Scientists are doing remarkable work. The summary dismissal that ‘we still don’t understand the biology of depression’ misrepresents the reality. We know a lot, and it was fun to try to make the new findings understandable.”

I came away from reading the book thinking that “Listening to Prozac” is a rich exploration by a doctor who clearly was closely listening and responding to his patients, with an inquisitive and caring ear.

“Listening to Prozac: The Landmark Book About Antidepressants and the Remaking of the Self,” by Peter D. Kramer, $19. Available for order through Edgartown Books, Bunch of Grapes, or online.