In:In 1993, I published a book, Listening to Prozac, based on my clinical experience prescribing a then-new class of drugs believed to moderate depression by working with the brain’s neurotransmitter serotonin.
Some of my patients have reported markedly favorable reactions to the drugs; first Prozac and soon Zoloft. With medication, patients were more confident, less anxious, and less pessimistic. They felt better than even before the episode we were treating, depression or increased mania. One patient said that he was finally himself, as if it were not for the new drug formulation, he would never have been himself. In the book, I tried to explain how these consequences might arise, and then discuss the implications for medical ethics and society in general. How flexible is the self? How open are we to technologies that can change that?
Listening to Prozac became a national and international bestseller and has been in print ever since. The book is now available in a 30th anniversary edition with a new foreword and afterword in which I update the science and discuss changes in the cultural status of antidepressants. In short, we rely on them more but respect them less.
When I wrote the book, the responses that my patients expressed required an explanation. In the early 1980s, I served in the federal government, directing an agency that oversaw a wide range of mental health research. I turned to the experts I had worked with at the time, from cell biology to animal ethology, hoping to understand how compounds developed to treat major depression might affect personality. For the book, I built on that research and went on to explore the implications for medical practice. If these or future drugs can alleviate a trait such as shyness, which, while not abnormal, is uncomfortable and socially disadvantageous, should physicians use them for this purpose, practicing what I have called “cosmetic psychopharmacology”? :
I predicted that the new drugs would lead to new prescribing habits, perhaps what I called “diagnostic bracket creep,” an apparent rationale for treating less severe forms of depression. But even I didn’t foresee the magnitude of Prozac’s effect. In the late 1980s, perhaps one in 50 Americans received a prescription for an antidepressant each year, and the duration of treatment was usually months. Recently, use has risen to more than a seventh, and some patients have been taking the medication for decades.
Advanced administration and the passage of time have relegated antidepressants to their primary role in treating mood disorders. Antidepressant survivor groups are taking to social media to complain about the drugs’ adverse effects. Within the professions, the antipsychotic movement has rallied, arguing that antidepressants are little more than placebos with side effects and that the brain’s use of serotonin plays no role in depression. I discuss these objections in detail in the new essays in Listening to Prozac, as well as in my earlier nonfiction book, Ordinarily Fine. My point is that we’ve been pretty lucky with drugs in terms of side effects and very lucky in terms of major effects. They have relieved the suffering of millions of patients.
Perhaps unexpectedly, there is less argument about better outcomes, effects on temperament, and again, here, I seem to have underestimated the phenomenon. Post-writing research on “Listening to Prozac” shows that it and similar antidepressants are particularly effective in alleviating introversion and neuroticism, negative thinking, uncomfortable self-consciousness, emotional vulnerability, and instability. Personality effects may be more pronounced than antidepressant effects and may be partially responsible for them. No one disputes that serotonin is involved. Similar changes occur throughout the animal kingdom, where manipulations of serotonin can predispose males to alpha status. When Prozac makes its way into the water supply, which it unfortunately does, regularly and in large quantities, some fish can become extremely bold and therefore vulnerable.
Today, the most common question I get about “listening to Prozac” is whether, over the years, I have continued to see dramatic good responses to antidepressants, results that my patients and I have called “better than good.” The answer is: less often, but not for the reasons you might think.
When Listening to Prozac became a bestseller, my clinical practice changed. I saw patients in a private practice in Providence, Rhode Island and enjoyed treating patients with a wide range of diagnoses.
But regardless of my intentions as an author—I thought I was writing about the reconstruction of a modern sense of identity—readers saw my book as a resource for understanding depression, and they came to me for help in a complex and often difficult way. treat forms of mood disorder; Try to keep my patient mix local and diverse as much as possible; I liked being a small town doctor. practice became more national and specialized.
People sought me out because they had done badly elsewhere. Rarely was I the first doctor to put a patient on a drug like Prozac. I have only occasionally treated first and second episodes of depression that were not complicated by other psychiatric conditions.
My experience represented an extreme version of what happened in psychiatry. If a family doctor were to write prescriptions for antidepressants and patients found relief, as is the case in most cases, they would never see a mental health professional. Like myself, my psychiatric colleagues mostly treated the rest, the patients who were not helped, or only partially helped, with a simple prescription.
When I worked in public health, beginning in the Carter administration, one of our goals was to get primary care physicians to recognize and treat depression. Prozac, which is easier for doctors to administer than previous antidepressants, has done this. It was these generalists who were now seeing patients gain assertiveness and social competence.
At the same time, medical professionals’ understanding of mood disorders changed. Depression is characterized by a cluster of symptoms: deep sadness, obsessive self-blame, slowed thinking and speech, eating and sleeping problems, suicidal thoughts, loss of pleasure, etc. In the 1980s, if a patient’s depressive episode resolved, if their sleep, appetite, and energy improved, and they returned to being passive, pessimistic, and socially withdrawn, the drug had done its job. But after seeing patients do better on the new antidepressants, doctors now often saw the melancholic temperament as a residual illness.
And residual disease can be harmful. One of the big changes of the past three decades has been the awareness among physicians of chronic low-level mood disorder and the risk it carries not only for suicide but also for common poor life outcomes, including limited success in love and work. The once-sharp divide between depression as a disease and depressed temperament began to blur, so that some of what I had understood as personality change became incorporated into doctors’ picture of normal recovery from depression. Crawling into this diagnostic bracket seemed to me conceptually wrong—think of those bold fish—but sometimes justified clinically.
Patients were also neutral on this topic. Of course, some of the controversy surrounding the long-term use of prescription drugs stems from patient preferences. Even between episodes of mood disorder, some patients who are prone to depression find that they respond better to medication and worse.
I stopped treating patients five years ago and have been writing full-time ever since. Until then, I continued to see dramatic favorable responses to antidepressants. But I heard or read about them more often. Readers often wrote, and still do, to tell me that they resembled this or that patient in the vignettes of my book. And people who feel more socially competent about medication sometimes share their experiences in the press or on social media.
Not long ago, I was asked to endorse an insightful nonfiction book by journalist Rachel Aviv. He expresses skepticism about medication and often about mental health care in general. As a journalist, Aviv was known for publicizing the difficulties some patients report coming off antidepressants.
But Aviv, as he writes in the book. Strangers to us — had a life-changing reaction to one of Prozac’s younger cousins, Lexapro. After much hesitation, while taking medication, Aviv decided to get pregnant. Then, for the sake of the fetus, she left herself, and then she no longer remembered why she wanted to have a child. After being medicated, she found motherhood natural again. Aviv later found that she was a better parent to her children when she was on the medication, although she began tapering off again while writing the book, 10 years after her introduction to the drug.
I continue to collect stories of personality change on medication. Some cases, like Aviv’s, are seen as mixed blessings. The positivity of the welcome is tainted by concerns about what it means to be in medicine, mind and body, and patient identity. How complex are the interactions between drug use, life choices, and family functioning? The stories of these patients reassure me that, 30 years later, the question at the heart of Listening to Prozac remains fresh and relevant: the question of medication and the nature of the self.
Peter D. Kramer is the author of the recent novel.The death of a great man“. He is professor emeritus of psychiatry and human behavior at Brown University.
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