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Should We Still Listen to Prozac? Peter D. Kramer Jumps Back Into the Antidepressant Debate Should We Still Listen to Prozac? Peter D. Kramer Jumps Back Into the Antidepressant Debate
(about 17 hours later)
ORDINARILY WELLThe Case for AntidepressantsBy Peter D. Kramer310 pp. Farrar, Straus & Giroux. $27.ORDINARILY WELLThe Case for AntidepressantsBy Peter D. Kramer310 pp. Farrar, Straus & Giroux. $27.
In 1993, the psychiatrist Peter D. Kramer erupted into public consciousness when he published his second book, “Listening to Prozac,” which became one of the signature cultural artifacts of its time, fodder for cartoons and humor pieces in The New Yorker (most notably Louis Menand’s classic “Listening to Bourbon”) and for dinner-party and ­medical-school-lounge conversations across the country. Though the book was controversial in some circles — Sherwin Nuland savaged it in The New York Review of Books, and it provoked a slew of opposing books (including, inevitably, “Talking Back to Prozac”) — “Listening to Prozac” helped reframe the context in which patients and physicians thought about what was then a new class of drugs, the S.S.R.I.s, or selective serotonin reuptake inhibitor antidepressants. The book wove together science, history, literature, philosophy and case studies and remains one of the best philosophical meditations on the age of biological psychiatry.In 1993, the psychiatrist Peter D. Kramer erupted into public consciousness when he published his second book, “Listening to Prozac,” which became one of the signature cultural artifacts of its time, fodder for cartoons and humor pieces in The New Yorker (most notably Louis Menand’s classic “Listening to Bourbon”) and for dinner-party and ­medical-school-lounge conversations across the country. Though the book was controversial in some circles — Sherwin Nuland savaged it in The New York Review of Books, and it provoked a slew of opposing books (including, inevitably, “Talking Back to Prozac”) — “Listening to Prozac” helped reframe the context in which patients and physicians thought about what was then a new class of drugs, the S.S.R.I.s, or selective serotonin reuptake inhibitor antidepressants. The book wove together science, history, literature, philosophy and case studies and remains one of the best philosophical meditations on the age of biological psychiatry.
The book made Kramer famous — or at least famous for an academic psychiatrist. People referred to him as “that Prozac man” or “Dr. Prozac.” But he didn’t want that label to define him, so while he continued to write about mental health in books like “Against Depression” and a brisk biography of Sigmund Freud, he stayed out of “the antidepressant wars” for more than decade.The book made Kramer famous — or at least famous for an academic psychiatrist. People referred to him as “that Prozac man” or “Dr. Prozac.” But he didn’t want that label to define him, so while he continued to write about mental health in books like “Against Depression” and a brisk biography of Sigmund Freud, he stayed out of “the antidepressant wars” for more than decade.
Actually, debates about the ethics and efficacy of psychopharmacology long predate Prozac’s arrival in the late 1980s, having raged with varying levels of intensity since the first modern psychiatric drugs came to market starting in the 1950s. Do drugs work? Do they impede psychotherapy? Do they threaten the professional standing of psychoanalysts and nonprescribing psychologists? (The answer to that last question has, at times, been definitively yes.) But the most recent battle in the war was launched in 1998, when the psychologist Irving Kirsch fired a salvo in the form of an academic-journal essay called “Listening to Prozac but Hearing Placebo,” in which he argued that antidepressants were much less effective than was generally believed. He published a book along the same lines in 2010 called “The Emperor’s New Drugs: Exploding the Antidepressant Myth.” Using a relatively new (and in Kramer’s view, somewhat questionable) research methodology called meta-analysis — in essence, combining the findings of many individual controlled studies to derive one giant statistical takeaway — he concluded that to the extent antidepressants did work, their operative mechanism was based nearly as much on the placebo effect as on the actual chemical action of the drug.Actually, debates about the ethics and efficacy of psychopharmacology long predate Prozac’s arrival in the late 1980s, having raged with varying levels of intensity since the first modern psychiatric drugs came to market starting in the 1950s. Do drugs work? Do they impede psychotherapy? Do they threaten the professional standing of psychoanalysts and nonprescribing psychologists? (The answer to that last question has, at times, been definitively yes.) But the most recent battle in the war was launched in 1998, when the psychologist Irving Kirsch fired a salvo in the form of an academic-journal essay called “Listening to Prozac but Hearing Placebo,” in which he argued that antidepressants were much less effective than was generally believed. He published a book along the same lines in 2010 called “The Emperor’s New Drugs: Exploding the Antidepressant Myth.” Using a relatively new (and in Kramer’s view, somewhat questionable) research methodology called meta-analysis — in essence, combining the findings of many individual controlled studies to derive one giant statistical takeaway — he concluded that to the extent antidepressants did work, their operative mechanism was based nearly as much on the placebo effect as on the actual chemical action of the drug.
Still, anxious to escape being permanently identified as Prozac Man, Kramer kept his counsel. But as the assault on antidepressants continued, he realized he needed to join the battle: The stakes of defeat in the antidepressant wars were just too high for depressed patients. In 2011, after Dr. Marcia Angell, the former editor of The New England Journal of Medicine, published a series of pieces in The New York Review of Books in which she drew on Kirsch’s work as well as the journalist Mark Whitaker’s book “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America” to conclude that “psychoactive drugs are . . . worse than useless,” Kramer donned his cape again, like Batman returning to save Gotham, and took to the pages of this newspaper to publish “In Defense of Antidepressants.” Prozac Man was back! Still, anxious to escape being permanently identified as Prozac Man, Kramer kept his counsel. But as the assault on antidepressants continued, he realized he needed to join the battle: The stakes of defeat in the antidepressant wars were just too high for depressed patients. In 2011, after Dr. Marcia Angell, the former editor of The New England Journal of Medicine, published a series of pieces in The New York Review of Books in which she drew on Kirsch’s work as well as the journalist Robert Whitaker’s book “Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America” to conclude that “psychoactive drugs are . . . worse than useless,” Kramer donned his cape again, like Batman returning to save Gotham, and took to the pages of this newspaper to publish “In Defense of Antidepressants.” Prozac Man was back!
Or perhaps the more apt metaphor is this one: Like Victor Frankenstein, who created a monster, Kramer realized he ought to rein in some of the potentially damaging concepts he’d loosed on the world. In “Listening to Prozac,” Kramer had coined two terms that got absorbed into conversations about the morality of medicating depression: “better than well” and “cosmetic psychopharmacology.” Both speak to his misgivings about the widespread prescription of antidepressants. He had expressed philosophical reservations about the consequences of medicating people who were not suffering from clinical levels of emotional distress, and who were in effect using the new class of antidepressants as performance-­enhancing drugs, to make themselves more confident at work or more sociable at parties. Were Prozac and its ilk the new opiate of the masses?Or perhaps the more apt metaphor is this one: Like Victor Frankenstein, who created a monster, Kramer realized he ought to rein in some of the potentially damaging concepts he’d loosed on the world. In “Listening to Prozac,” Kramer had coined two terms that got absorbed into conversations about the morality of medicating depression: “better than well” and “cosmetic psychopharmacology.” Both speak to his misgivings about the widespread prescription of antidepressants. He had expressed philosophical reservations about the consequences of medicating people who were not suffering from clinical levels of emotional distress, and who were in effect using the new class of antidepressants as performance-­enhancing drugs, to make themselves more confident at work or more sociable at parties. Were Prozac and its ilk the new opiate of the masses?
One of the central ironies of “Listening to Prozac’s” reception is that it generated two opposed responses, both of which got deeply imprinted on the culture. One was that Prozac and other S.S.R.I. antidepressant drugs were miracle pills that could not only treat depression but also make people “better than well.” The contrary response, which emanated from Kramer’s own openly expressed misgivings about the risks of medications that potentially altered personality, was that we ought to be wary of widely prescribing such antidepressants. As Kramer’s nuanced thinking leached into the public discourse, a misreading of his thinking contaminated his actual view, which was that antidepressants can work — can in fact be lifesavers — but that we ought to be aware of the social implications of their widespread prescription.One of the central ironies of “Listening to Prozac’s” reception is that it generated two opposed responses, both of which got deeply imprinted on the culture. One was that Prozac and other S.S.R.I. antidepressant drugs were miracle pills that could not only treat depression but also make people “better than well.” The contrary response, which emanated from Kramer’s own openly expressed misgivings about the risks of medications that potentially altered personality, was that we ought to be wary of widely prescribing such antidepressants. As Kramer’s nuanced thinking leached into the public discourse, a misreading of his thinking contaminated his actual view, which was that antidepressants can work — can in fact be lifesavers — but that we ought to be aware of the social implications of their widespread prescription.
In “Ordinarily Well,” Kramer tills some of the same ground that he did in his previous book, but his approach this time is less philosophical and more argumentative. He is out to make the case, against the Marcia Angells and Irving Kirsches of the world, that, based on his interpretation of the literature and, more important, on his decades of clinical work with patients, antidepressants work more often than not and that, most of the time, prescribing an antidepressant is not about making somebody “better than well” but rather helping to relieve a patient’s acute suffering enough that she can resume a semblance of normal life. He burrows deep into the studies that ostensibly show the ­limited efficacy of antidepressants — which makes “Ordinarily Well,” in large part, a book about research methodology, an exploration of the merits of the double-blind controlled study and the meaning and practice of “evidence-based medicine.” He essays explanations of “effect sizes” and “standard deviations,” and dives into an alphabet soup of acronyms to explore the differences between, for instance, the HAM-D17 and the HAM-D6 (two versions of a widely used depression-rating scale developed in the 1970s that had helped establish the effectiveness of imipramine, an early antidepressant in what’s known as the tricyclic class of drugs).In “Ordinarily Well,” Kramer tills some of the same ground that he did in his previous book, but his approach this time is less philosophical and more argumentative. He is out to make the case, against the Marcia Angells and Irving Kirsches of the world, that, based on his interpretation of the literature and, more important, on his decades of clinical work with patients, antidepressants work more often than not and that, most of the time, prescribing an antidepressant is not about making somebody “better than well” but rather helping to relieve a patient’s acute suffering enough that she can resume a semblance of normal life. He burrows deep into the studies that ostensibly show the ­limited efficacy of antidepressants — which makes “Ordinarily Well,” in large part, a book about research methodology, an exploration of the merits of the double-blind controlled study and the meaning and practice of “evidence-based medicine.” He essays explanations of “effect sizes” and “standard deviations,” and dives into an alphabet soup of acronyms to explore the differences between, for instance, the HAM-D17 and the HAM-D6 (two versions of a widely used depression-rating scale developed in the 1970s that had helped establish the effectiveness of imipramine, an early antidepressant in what’s known as the tricyclic class of drugs).
This makes for less enthralling reading than “Listening to Prozac.” But Kramer is not out to enthrall but rather to re-­engage with an important debate that’s been brewing since the dawn of biological psychiatry: Do antidepressants work? Kramer argues forcefully that they do.This makes for less enthralling reading than “Listening to Prozac.” But Kramer is not out to enthrall but rather to re-­engage with an important debate that’s been brewing since the dawn of biological psychiatry: Do antidepressants work? Kramer argues forcefully that they do.
There have been many books published on both sides over the last few decades. This book would be yet another contribution to the literature of pro- and antidrug jeremiads except that it is so careful and measured and fair, and at times even candidly self-doubting, in its presentation, that it can’t be classified as such. Though the book cautions against the putative certainties of “evidence-based medicine” and presents a case for the superiority of clinical wisdom over statistical analysis, Kramer evinces such humility that no one could accuse him of being a pro-­medication ideologue. (He has never taken money from a drug company.) In fact, late in the book, after 200 pages of arguing that antidepressants work effectively, Kramer reveals that he himself is conservative in, if not hesitant about, prescribing antidepressants. “I rely heavily on psychotherapy, often postponing prescribing until I hit a roadblock,” he writes. “Even then, I tend, relative to the literature, to undermedicate patients, in every way — lower doses at shorter duration.”There have been many books published on both sides over the last few decades. This book would be yet another contribution to the literature of pro- and antidrug jeremiads except that it is so careful and measured and fair, and at times even candidly self-doubting, in its presentation, that it can’t be classified as such. Though the book cautions against the putative certainties of “evidence-based medicine” and presents a case for the superiority of clinical wisdom over statistical analysis, Kramer evinces such humility that no one could accuse him of being a pro-­medication ideologue. (He has never taken money from a drug company.) In fact, late in the book, after 200 pages of arguing that antidepressants work effectively, Kramer reveals that he himself is conservative in, if not hesitant about, prescribing antidepressants. “I rely heavily on psychotherapy, often postponing prescribing until I hit a roadblock,” he writes. “Even then, I tend, relative to the literature, to undermedicate patients, in every way — lower doses at shorter duration.”
Kramer tells three stories that are especially convincing. The first is about Osheroff v. Chestnut Lodge, a court case from the early 1980s. Raphael Osheroff, a kidney doctor who had been felled by anxiety and depression, ended up in a psychoanalytically oriented inpatient facility in Maryland, Chestnut Lodge, that eschewed medication. He deteriorated so dramatically there that a friend moved him to a different facility, which medicated him, allowing him to promptly recover. The ensuing court case — based on the failure of Chestnut Lodge to prescribe medication — played out over a number of years and was ultimately settled in Osheroff’s favor. It changed how the field approached prescribing; from that point on, the failure to prescribe antidepressants or other psychotropic medications could be grounds for a malpractice suit.Kramer tells three stories that are especially convincing. The first is about Osheroff v. Chestnut Lodge, a court case from the early 1980s. Raphael Osheroff, a kidney doctor who had been felled by anxiety and depression, ended up in a psychoanalytically oriented inpatient facility in Maryland, Chestnut Lodge, that eschewed medication. He deteriorated so dramatically there that a friend moved him to a different facility, which medicated him, allowing him to promptly recover. The ensuing court case — based on the failure of Chestnut Lodge to prescribe medication — played out over a number of years and was ultimately settled in Osheroff’s favor. It changed how the field approached prescribing; from that point on, the failure to prescribe antidepressants or other psychotropic medications could be grounds for a malpractice suit.
The second example involves Robert Liberman, who, as a medical student in 1961, published one of the first influential papers questioning the efficacy of psychiatric medication, “A Criticism of Drug Therapy in Psychiatry,” which argued (to oversimplify) that antidepressants like imipramine didn’t work — and to the extent that they did, it was due to the placebo effect. Liberman ended up as a psychiatrist at Johns Hopkins, where he became depressed. Talk therapy didn’t relieve his woes — but taking an antidepressant did.The second example involves Robert Liberman, who, as a medical student in 1961, published one of the first influential papers questioning the efficacy of psychiatric medication, “A Criticism of Drug Therapy in Psychiatry,” which argued (to oversimplify) that antidepressants like imipramine didn’t work — and to the extent that they did, it was due to the placebo effect. Liberman ended up as a psychiatrist at Johns Hopkins, where he became depressed. Talk therapy didn’t relieve his woes — but taking an antidepressant did.
The final story may be the most dispositive. When Kramer began visiting psychiatric wards in the 1970s, they were filled with miserable, hollowed out people who were in what was then known as “end-state depression”; the only thing that differentiated these patients from psychotically catatonic patients is that these depressed patients would wring their hands. Kramer — and everyone he’s talked to — have not seen such patients in decades, a development he attributes to the advent of aggressive antidepressant prescription to forestall such dire outcomes.The final story may be the most dispositive. When Kramer began visiting psychiatric wards in the 1970s, they were filled with miserable, hollowed out people who were in what was then known as “end-state depression”; the only thing that differentiated these patients from psychotically catatonic patients is that these depressed patients would wring their hands. Kramer — and everyone he’s talked to — have not seen such patients in decades, a development he attributes to the advent of aggressive antidepressant prescription to forestall such dire outcomes.
Kramer is out to win the “antidepressant wars” in favor of the antidepressants. Is he right? I can’t say definitively that he is. Nobody could, or these drug debates would already have ended. But in my judgment he is. One can question whether I’m qualified to make that judgment. I’m neither a psychiatrist nor a statistician. But as the author of a book on mental illness, I’ve read deeply in the scientific and historical literature, including all the books attacking Big Pharma. Perhaps more relevantly, I have copious experience with taking antidepressants. Can I say with 100 percent certitude that they’ve worked? No. In fact, some of those drugs definitively did not work for me, and sometimes made my anxiety worse, or created inconvenient and, at times, intolerable side effects. But I’m pretty sure that without the tricyclic antidepressants of the 1980s I wouldn’t have made it through middle school without inpatient hospitalization. And Paxil gave me the closest I’ve ever had to full remission from anxiety and depression symptoms for about eight months in 1997 before it lost its effectiveness. Could this all have been placebo effect? Coincidence? Or even something as ineffable as the quality of my personal interactions with my psychopharmacologists, which some studies have shown can have a significant effect on a patient’s response? Perhaps. But I don’t think so. And, as Kramer amply demonstrates, reams of clinical anecdote, as well as a proper reading of the statistical research data, suggest otherwise.Kramer is out to win the “antidepressant wars” in favor of the antidepressants. Is he right? I can’t say definitively that he is. Nobody could, or these drug debates would already have ended. But in my judgment he is. One can question whether I’m qualified to make that judgment. I’m neither a psychiatrist nor a statistician. But as the author of a book on mental illness, I’ve read deeply in the scientific and historical literature, including all the books attacking Big Pharma. Perhaps more relevantly, I have copious experience with taking antidepressants. Can I say with 100 percent certitude that they’ve worked? No. In fact, some of those drugs definitively did not work for me, and sometimes made my anxiety worse, or created inconvenient and, at times, intolerable side effects. But I’m pretty sure that without the tricyclic antidepressants of the 1980s I wouldn’t have made it through middle school without inpatient hospitalization. And Paxil gave me the closest I’ve ever had to full remission from anxiety and depression symptoms for about eight months in 1997 before it lost its effectiveness. Could this all have been placebo effect? Coincidence? Or even something as ineffable as the quality of my personal interactions with my psychopharmacologists, which some studies have shown can have a significant effect on a patient’s response? Perhaps. But I don’t think so. And, as Kramer amply demonstrates, reams of clinical anecdote, as well as a proper reading of the statistical research data, suggest otherwise.
If you can wade through the statistical and methodological thickets that Kramer, as your Virgil, leads you through in this book, you will most likely come away convinced by his argument for the efficacy of antidepressants — and moved by his humane concern for his patients, and for the needless suffering of unmedicated patients around the world.If you can wade through the statistical and methodological thickets that Kramer, as your Virgil, leads you through in this book, you will most likely come away convinced by his argument for the efficacy of antidepressants — and moved by his humane concern for his patients, and for the needless suffering of unmedicated patients around the world.