Dr. Peter Kramer was a general practice psychiatrist and philosopher who became intrigued and troubled by ethical issues proceeding from the introduction of SSRI medications in the 1980's. He cared enough about these concerns to pen "Listening to Prozac" in 1993, a best seller that, by his own exasperated admission, turned his own life upside down in terms of public perception. He was now "America's depression doctor," a position he neither sought nor relished. But, having been pushed up the steps of the bully pulpit, he decided to tackle his nemesis head-on, and the end product is our work at hand.
With his heightened sensitivity to depression, a new wave of depressed clients pounding his door, and countless speaking engagements and seminars, Kramer became aware that the medical condition of depression carried an aura of mystique and superiority that would never be tolerated in other disorders such as diabetes or cancer. Yes, individuals with painful diseases can grow in character through surgeries, chemotherapies, or deprivations. But no one actively cultivates the condition of cancer as an enhancement of the human situation.
Perhaps an irreverent title for this work might have been "A Tale of Two Prozacs," for the author divides his work into the misconceptions and canonizations of depressed mood, on the one hand, and the hard reality of this disease on the other. There is, he contends, a prevailing belief that mental health disorder and/or substance abuse unleashes creative energy and expands the life experience. As a psychotherapist myself, I do not need to revert to stories of Hemingway or Van Gogh. Nearly every teenager on psychotropic medication raises the question of whether "I'll still be myself." My reassurances that this is precisely our treatment goal are heard warily and with skepticism. They would probably agree with a doctor friend of mine who joked that if Prozac had been invented centuries ago, there would be no Irish folk music.
Kramer is fed up with the toleration of depression, particularly among adults, intellectuals, professionals, artists, and particularly some of his own colleagues. He assesses the false faces of depression, such as charm. He takes note of depressive stereotypes, such as the weak and sensitive depressed woman whose vulnerability presents an alluring attraction to men, or literature's subtle and continuous glorification of those who live as if life meant nothing. He decries the intellectuals' distrust of Carl Rogers for embracing enthusiasm instead of worshipping at the altar of alienation [100 ff.]
"Listening to Prozac" had been an excellent overview of the neurobiology of depression as understood in 1993, a time when the exchange of neurotransmitters such as serotonin dominated both conceptual thinking and pharmaceutical investigations. If LTP had been about a pill, AD describes what Prozac's offspring might look like, if they had been born yet. This of course is a major difference in Kramer`s two works: LTP begins with a pill, while AD begins with hypotheses. In this work Kramer examines more recent research that generally has not yet evolved into psychotropic medicine. One new source of depressive theory comes from Grazyna Rajkowska [52 ff.], an anatomist who explored the prefrontal cortex of the brain in autopsies. Under microscopic examination she found the cells of this region of the brain weakened, disorganized, disconnected, possibly but not certainly due to reduced blood flow to the region. Such a syndrome is seen in more intensive form in Huntington's and Alzheimer's Disease, a connection which, if continuously verified, would certainly lead to a paradigmatic shift in approaching the significance and treatment of depression.
Kramer does not discard the neurotransmitter model he described so eloquently in LTP. Present day treatment modalities, including Prozac, will continue to man the fort for the foreseeable future. But he argues persuasively that the theory is more complex than previously thought,. In his reviews of brain deprived neurotropic factor [120 ff.], 5-HTT genes as "stress police [130 ff.], Yvette Sheline's study of the hippocampus, and Fred Gage's theory of neurogenesis or the replacement of diseased neural cells, Kramer exudes less confidence that the secrets of depression will be unpacked soon, or that new generation miracle drugs will reach the corner pharmacy imminently.
Kramer's early concerns about depression medication as cosmetic have been replaced by concern and anger about the double standard regarding attitudes toward depression by the medical profession and the public alike. Kramer depicts depression as a killer, as dangerous as plague and prevalent in epidemic proportions. He argues that the disease must be attacked ruthlessly, and here he takes issue with what he sees as a somewhat casual approach to the disease by those who espouse psychotherapy as the long term answer, or those hesitant to medicate, or even those who consider the depressed state as a creative matrix or Nietzschian pose of alienation. Chapters 17 and 18 are perhaps the highlights of the work, where art, history, and culture come face to face with biology, in the philosophical style that made LTP such a pleasure to read.
LTP was a leisurely thoughtful work. AD is not. For the most part it is more scientific and certainly more polemical. LTP was speculative about the possibilities of psychiatry and medication. AD is acute in its assessment of the present, particularly regarding cultural attitudes toward this disease. I am struck by the impression that after over a decade as "America's depression doctor," the author is sounding more...well, depressed.
