Posted by Thomas J. Burns on 12/12/2003
I had a desire to go back and reread this work on the tenth anniversary of its publication. I was curious to see how Dr. Peter Kramer's magnificent essay of the mysteries of mood and matter had stood the test of time. I was also interested to see how far the psychiatric-pharmaceutical complex had come in the past decade in dealing with the scourge of depression and other mental disorders.
But before I get too far ahead of myself, exactly what was it about this book that made it such a provocative success in 1993? Two factors come to mind almost immediately. The first is the remarkable story-telling and philosophical style of the author. Yes, the crux of this work was the ethical dilemma of physicians who for the first time possessed the legal and medicinal power to alter personality cosmetically. But we forget over the years that this book was much more than a pharmaceutical morality play. It was a fascinating look at the pioneers of the biotechnology era, a glimpse into the hit and miss processes whereby paradigms and hypotheses were transformed into molecular formulas. The author made lucid for the general public just how mysterious the matrix between the material and the metaphysical truly is. That the new psychotropic drugs could morph a wallflower into a grand dame was becoming evident, so to speak, but the reasons for the change remained well educated guesses, and nothing more, in 1993. Such a tale was both tantalizing and troubling, and no one before Kramer had quite animated psychiatry while circumscribing it in such an elegant way.
The second attraction of this book was the drug itself, Fluoxetine, marketed under the brand name Prozac. Prozac was not the only member of new wave antidepressants, the Selective Serotonin Reuptake Inhibitors, or SSRI's, available in 1993. [Zoloft was on the market by then.] But Prozac intrigued the public for different reasons than it enthralled Dr. Kramer. Prozac had a public relations problem: allegedly it promoted suicide and other evils, charges easily discredited with time but not until the medication had run the Larry King/60 Minute gamut of journalistic fury. Kramer did for Prozac what the Crocodile Hunter would later do for venomous reptiles, remind us that though potent the SSRI's can be handled safely by trained professionals.
It has been ten years since this work was published, and seventeen years since the appearance of Prozac. Have we grown in wisdom regarding the relation of mood and chemicals in the human nervous system, and have we seen a stampede of new clients looking for psychological facelifts from new generation psychotropics? To respond to the first question, pharmaceutical inquiry over the past decade has continued to focus upon the neurotransmitter model of cellular communication in the brain--the cute Zoloft TV cartoon of little bullets or messengers passing back and forth between mother ships. There is now question as to whether Serotonin is the only bullet in the holster, with researchers looking at the roles of dopamine and norepinephrine in the alteration of mood. Moreover, the SSRI's have proven effective over time with more disorders besides depression--everything from obsessions to pain management. But no new major theory of mood disorder has displaced those discussed by Kramer. The kindling theory of illness described by Kramer [110ff.] and the genetic disposition toward illness in successive generations of families seem to have created more interest in pediatric psychiatry and the importance of early intervention. What has certainly changed in a decade is Prozac's reputation; it is now the safe old plow horse of the stable, the only SSRI considered truly tolerable for minors.
As to the second issue, personality enhancement, Kramer's worries may have been misplaced. Kramer was low keyed in his discussion of side effects, but the SSRI's have been bedeviled by them to the present day. Most notably the sexual side effects have put a damper upon elective use of the medication. Sexual impairment is a high price to pay for enhanced self confidence, though new formulations and time release capsules have ameliorated the side effects some. [The real stampede, ironically, has been toward Viagra.] But when push comes to shove, the past decade indicates that, bottom line, Americans continue to entertain a pharmaceutical Calvinism, a suspicion of medicine, and more recently, of the companies that make them. When I undertake a mental health assessment, the first question I get is inevitably: "You're not going to recommend drugs, are you?" One common example: parents resist stimulants for their ADHD children like the plague. Contrary to popular belief, America is not a country of eager pill poppers, and this has been true even before the recent surge in medicine costs. Pills are for "when you're sick."
If anything, there is a thinly veiled contempt for medical interventions that enhance the human experience beyond convention. Evidently there is a national consensus that every man deserves a good erection. But buried deep in the national subconscious is the spirit of the Hippocratic Oath. Or, conceivably, we have taught people to "just say no" a little too indiscriminately where medication is concerned. But by and large cosmetic physical interventions still carry a certain stigma. There is a slight revulsion to the idea that Barry Bonds' 73 home runs were steroid enhanced, or that Pamela Anderson's prime assets are [or were] primarily silicone. There have been pharmaceutical betrayals, too, in the last ten years, notably Redux and Fen Fen. In retrospect Kramer's fears about the ethics of altering personality have been trumped by the inbred suspicion of the "quick fix." Who among us does not hold an innate suspicion of ads for "miracle weight loss?" A nation reluctant to eat a steady diet of meat to lose weight is probably not ready for instant personality remakes.