Extended Interview: Peter D. Kramer

SUSAN DENTZER:

How has Prozac changed the practice of psychiatry and psychology in America?

PETER KRAMER:

I think Prozac has helped change what constitutes our sense of a complete treatment of depression. Years ago, certainly when I was in training, if you had a patient who had an acute episode of depression, who was very sad, maybe suicidal, could barely move from the chair, if you could treat that acute episode, give relief, and in the end the patient had low energy, was pessimistic, had low self-esteem, that was a successful treatment. It ended the episode of depression.

I think the fact that some patients responded much more dramatically to these medicines and really lost not just — didn't just end that acute episode of depression, but lost some of the depressive aspects of personality, changed doctors' sense of what an end point is, probably changed people's sense in general of what an end point is.

Now, there are other reasons for this. There's been research showing that having as a residual even a few symptoms of depression for a short while predicts a relapse. That is, people are going to relapse — are more likely to relapse. So there are other reasons to push the treatment of depression further.

But I think Prozac was a big influence, and I think now if you have a patient who recovers from an episode of depression and who remains pessimistic, and self-doubting, and shy, both doctor and patient are likely to say the treatment isn't done. Really more needs to be done just for the person to be safe. And I think that is a direct effect of the introduction of these new medicines.

SUSAN DENTZER:

The debut of Prozac and the growth of the market of Prozac also coincided with the growth of managed care, which was at the same time putting pressure on psychotherapy and other forms of treatment. How has all this come together in transforming —

PETER KRAMER:

I think that was a most unfortunate coincidence. I think these would be the glory days of psychiatry — they may be the glory days of psychiatry, but they really would be if there were a chance to combine these new anti-depressants with psychotherapy, and to take patients, have them in psychotherapy for a while. If they then need medication, to say, you know, if only I could change this aspect for a little while, just help the patient to have another perspective for a short while, introduce the medicine, withdraw it later. I think that would be the ideal treatment of many patients.

As it is with managed care, I think patients are rushed onto medicines and, in fact, the research on managed care seems to show that patients are put on medicine with very little follow-up, and they aren't even given the medicines to very good effect, so that these new medications that were meant to be such a boon to mankind because of the medical system that they're being put into, may end up just being another pretext to allow depressed people to go on suffering.

These are the central issues. I think they are very interesting ethical and social issues regarding the treatment of minor mood disorders, and personality styles that for most of human history would have been accepted as normal aspects of the melancholic temperament. But the central public health issues are still the treatment of depression, and there certainly the advent of managed care has been disastrous.

SUSAN DENTZER:

Is Prozac being over-used, under-used, or is it about right?

PETER KRAMER:

I think I can say with some certainty that nobody knows. Depression is so under-treated that probably you could still double the volume of anti-depressants being used just to treat people where almost every doctor would say yes, this is an appropriate use of medication.

On the other hand, it turns out to be very hard to do the research to know whether the anti-depressants already described are going to the right people. My own sense is I serve sort of as a clearinghouse for stories about Prozac. People write me, they call me, and I have yet to see the egregious case. I've seen people on Prozac who probably didn't fit a precise psychiatric diagnosis, but something was going on where they were suffering profoundly in some way, or having very substantial troubles functioning.

I have not seen the casual use of the medicine, although I know that that is, you know, a story throughout the culture.

SUSAN DENTZER:

Let's go back for a moment and talk about the experience that you have many patients describe to you, and you put a label on it. You called it better than well. What did you mean by better than well?

PETER KRAMER:

The typical early troubling story with Prozac was the following. A patient comes in for an indication that ordinarily requires medication or could use medication as part of the treatment — depression, obsessionality, and so on. The doctor — let's say I give the medication, patient gets better, stays on the medicine for a while, comes off, and then comes back in and says you know, I don't have that particular problem. I'm not depressed. But I was so much more comfortable, confident, assertive on the medicine. Could you prescribe that medication again. And I think that's the better than well problem. The patient is saying I was better than my baseline. I felt better than my baseline on the medicine. I'm not mentally ill. Will you give me the medicine?

I think the interesting question is how doctors respond to that request.

SUSAN DENTZER:

Why is being better than well a problem?

PETER KRAMER:

Well, I think the considerations of risk versus benefit are different for illness than they are for enhancement. I think that's — medical ethicists say that across the board — that is the ability to take more risks, have the patient take more risks to treat an illness than you would to move from one normal state to some other normal state that feels better or is more socially rewarded.

So I think that is the main issue. But I think beyond that we do have some discomfort about using medicines for that purpose because there are past experiences of unexpected side effects, and addiction in particular; that medicines that feel good, you know, people — there is some risk that people will overuse them.

Patients said they weren't just the way they were before the acute ailment struck them; that they actually on the medicine felt better than they had felt for a long time, and maybe even like their true self, that there was some feeling of authenticity.

And I coined the phrase cosmetic psychopharmacology to respond to that. That is, could we use — would we be tempted to use medicines the way surgeons use plastic surgery; that is, not just to repair gross defects, but actually to make people feel in a way that it's more desirable to feel, to give them traits that are more rewarded within the culture.