Coming of Age on Zoloft (13 page)

Listening to Prozac
is a book fueled by ambivalence. Prozac thrills Kramer the clinician: he portrays the drug as stupendously effective. But it unsettles Kramer the humanist profoundly. He believes that the pill fosters biological reductionism, revealing as chemical what Kramer and his patients alike had once considered psychological. “When one pill at breakfast makes you a new person,” Kramer writes, “it is difficult to resist the suggestion, the visceral certainty, that who people are is largely biologically determined.”
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And that thought seems to Kramer to cut against the notions of free will, personal responsibility, and the importance of trying hard, on which we’ve built our democratic society.

Kramer believes that Prozac has a way of instructing people about what’s pathological and what isn’t; that’s what is meant by the title of the book. Every quirk that yields to the drug’s effects is cast in a new light of suspicion: was it really a symptom of disorder all along? Kramer’s once-shy patient, Tess, eventually discontinues Prozac, but she returns to Kramer’s office some months later, complaining that she is “slipping”; she tells her doctor simply that without Prozac, “I am not myself.” Kramer is floored. “After all,” he writes, “Tess had existed in one mental state for twenty or thirty years; she then briefly felt different on medication. Now that the old mental state was threatening to re-emerge—the one she had experienced almost all her adult life—her response was ‘I am not myself.’ But who had she been all those years if not herself?”
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Kramer feels uneasy as he contemplates writing out a prescription for a person who in no way satisfies the definition he’d worked with all his adult professional life of any mental illness. He feels he is medicating not a disease but a personality. But Tess wants the Prozac, and he can’t see what harm it will do, so he reaches for his pad.

Kramer’s book is portentous but prescient. It both foresees and, in the way it sets up the debate,
creates
the future of our discourse about the SSRIs. The cover of the book features a graphic that I remember finding terrifying when I was in ninth grade and first saw a copy lying around my parents’ house. A figure of indeterminate gender, drawn in runny pastel, is lifting off his/her own face as though it were a mask—pulling it straight off the top of his/her own head like the burned outer layer of a marshmallow toasted over a campfire. Underneath there is no face at all, just a streaming void of flesh tones. Kramer was afraid that Prozac would obliterate the self as we knew it—that it would usher in an age where all the features of our personalities, instead of being given and fixed, would become optional. (“Since you only live once, why not do it as a blonde? Why not as a peppy blonde?”
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) He coined the phrase “cosmetic psychopharmacology”
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for this hypothetical state of affairs, and though he couldn’t put his finger on how he could object to the practice on ethical grounds, it nevertheless filled him with unease. It seemed to threaten the whole enterprise of psychiatry, which was, at least when Kramer had done his training, about finding meaning in suffering and making deliberate, incremental change. Prozac, he fretted, might even overturn the “continuous, autobiographical human self,” which had been psychiatry’s one true subject.
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The appeal of cosmetic psychopharmacology is obvious. Who among the striving, white-collar people who read the book wouldn’t identify the usefulness of a substance that caused a state not of intoxication but of hypereffectiveness: increased energy, reduced social friction? Kramer described a drug that could make you more relaxed in your dealings with others, warmer, more focused on business and pleasure alike. Kramer may have been iffy about his subject, but his best-selling book was probably one of the best pieces of promotion that the drug could possibly get. It’s hard to imagine that
Listening to Prozac
didn’t inspire a lot of people to have a chat with their doctors about whether an SSRI was right for them.

And yet Kramer wasn’t the only one who found the notion of a world where every aspect of our personalities is up for revision unsettling. If there was something about the pill Kramer described that inspired desire in us, there was also something that stimulated fear. Feeling “better than well,” as Kramer called the state that Prozac could induce in some, sounded tantalizing on the one hand, but uncanny and maybe even repellent on the other.

There’s a
New Yorker
cartoon from around this time that I like because its humor hangs on both of these reactions. It’s a three-frame strip titled “If They Had Prozac in the 19th Century.” Each frame is an oil-pastel portrait of a heavyweight thinker, looking happy and saying something inane. Karl Marx is smiling; he looks like Santa Claus. “Sure!” he’s exclaiming. “Capitalism can work out its kinks!”
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The cartoon is funny because it zeroes in, absurdly, on our hopes and fears about Prozac. Marx just seems so cheerful. Who wouldn’t want to be cheerful like that? And yet if Marx had been happier in a gee-whiz kind of way, he wouldn’t have been the Marx we know. There’d have been no
Communist Manifesto
; history might have run a different course. Would this have been better for Karl Marx? For the rest of the world? The awkwardness of not knowing, the absurdity of weighing something like Marx’s intellectual legacy against something like the idea of perkiness, is what produces the laugh. This was the dilemma of cosmetic psychopharmacology: we wanted to be happy but we worried that maybe there was something even more important than happiness that we’d unwisely be giving up in the bargain.

THE UNEASY PROSPECT
raised by
Listening to Prozac
, of a world chemically purged of shyness, orneriness, and roughness-around-the-edges, helps to explain one notable feature of our national conversation about antidepressants. It is in light of the fears awakened by the idea of cosmetic psychopharmacology and the objections inherent in the romantic critique of antidepressants that we can best understand the claim, used so often in antidepressant advertisements and by psychiatrists and biologically oriented mental health advocacy groups from the 1990s on, that depression is a “real” disease with physical causes. In chapter 2, I talked about the rise of the biomedical model of depression. That rise occurred for a variety of reasons, ranging from the discovery of antidepressants themselves to the psychiatric profession’s determination to break out of its humanistic mind-set and become more like the rest of medicine. But the biomedical model of depression also caught on because it was a useful rhetorical tool for selling antidepressants to a public that was wary about taking pills that might change the self, or constitute a mere palliative against the sorrows of everyday life.

Aside from the question of its correctness or incorrectness, the biomedical model of depression was a good way of countering those fears. Accordingly, ad campaigns and other promotional statements for antidepressants have consistently constructed depression—and the other conditions that antidepressants are prescribed for—as true diseases, a logic that paints antidepressants as real medicines, not all-purpose mood brighteners or, as Nathan Kline once described Marsilid, “psychic energizers.” If depression is truly an illness, after all, then antidepressants can’t be accused of being the chemical equivalent of rhinoplasty.

The claim that depression is a bona fide disease has been promoted almost as heavily over the years as antidepressants themselves. For example, the first direct-to-consumer ad campaign for Prozac, which appeared in
Time
magazine in 1997, is at pains to educate its readers about depression’s status as a real disease of physical origin. Under a cartoonish drawing of a thundercloud and the headline “Depression Hurts,” informative text describes depression as a medical condition. “Depression isn’t just feeling down,” the copy reads. “It’s a real illness with real causes”—namely, the levels of serotonin in the body, which Prozac can help bring back to normal.
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Often, the claim that depression is a real disease is made more specific by likening it to a specific condition, most frequently diabetes. Examples of this comparison crop up everywhere. In the instruction manual for a major, National Institute of Mental Health (NIMH)–funded clinical study of antidepressants, physicians involved in the research were instructed to make sure that their patients “understand that depression is a disease, like diabetes or high blood pressure, and has not been caused by something the patient has or has not done.”
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Several people I interviewed about their own antidepressant use mentioned that doctors had used the diabetes metaphor to explain antidepressants to them at the beginning. Rachel said that when she was in high school and feeling reluctant to start antidepressants, “I heard metaphors from my psychiatrist and my mother about diabetes and how you have to treat that, and that what I was going through was no different.” When you start to listen, you hear the claim that “depression is a disease just like diabetes” over and over again—in educational materials, op-eds, and quotes from psychiatrists in newspaper and magazine stories.

Likening depression to diabetes sets up a direct analogy between antidepressants and insulin treatments. It portrays depression as a condition in which the body doesn’t make enough of a substance it’s supposed to have in abundance—serotonin is to insulin—and, by extension, casts antidepressants as a medically necessary treatment to address that lack. (The comparison also subtly hints that antidepressant use should be chronic and ongoing, as insulin therapy is. Like diabetes, it imagines depression as a permanent condition: something you manage, but not something you really get better from.)

Proponents of the depression-is-a-disease-like-diabetes view argue that their position is important not only because it’s correct, but also because it helps to undo a long-standing stigma that has been attached to depression. People with depression, the argument goes, have often been made to feel guilty and weak for not being able to “snap themselves out of it.” In contrast to damaging views from the past, which held depression to be a sin, a moral failing, or a character flaw, the biomedical model portrays depression as both real (it’s not something you can shake off or will yourself out of) and nobody’s fault. It’s something you develop or end up with through blind biological bad luck. Accordingly, there should be no more shame or stigma attached to treating depression with antidepressants than there is to a diabetic’s treating her diabetes with insulin injections.

Removing stigma is a laudable goal. And to the extent that the biomedical model has succeeded in lowering the social and psychological barriers that have kept people from seeking help for mental health problems, it deserves to be praised. But portraying depression as a disease like diabetes has also served less pure, or at least more purely pragmatic, goals. I mentioned that Americans are wary of the idea of taking a medicine that only blunts the ordinary pain of living—one that allows us to bear up a little better under our problems, without really solving them. This wariness had something to do with the demise of tranquilizers, which ran afoul of the FDA, the public, and the Rolling Stones because of their image as a treatment for the stresses and strains of everyday life. By depicting them as being functionally very different from tranquilizers, the biomedical model allowed antidepressants to avoid the same fate.

The makers of SSRIs could have marketed their new products as treatments for anxiety; indeed, in the early days, some looked into it. But after the 1980s, after tranquilizer makers had been slapped on the wrist by regulators for marketing their products as remedies for everyday tension, and after stories of tranquilizer addiction had flooded the media, a different approach seemed more desirable. To ensure that SSRIs didn’t end up with a “mother’s little helper” reputation, their manufacturers emphasized to doctors and consumers alike that depression was a real disease with biological causes, and that SSRIs were a proper medical treatment for that disease. The psychiatrist and historian of psychopharmacology David Healy has written that by the 1990s, the same symptoms that would have once gained someone a diagnosis of anxiety neurosis and a prescription for tranquilizers was likely to be diagnosed as a mood disorder and be treated with a prescription for an SSRI.

BUT WHY EXACTLY
are we so discomfited by the idea of pills that might tweak the self? Or by the thought of a drug that just slightly softens the edges of a painful world? Carl Elliott is a professor of bioethics, pediatrics, and philosophy at the University of Minnesota in Minneapolis. He writes about what he calls “enhancement technologies,” interventions at the interface of medicine and self-improvement that promise “to take the edge off of some sharply uncomfortable aspects of American social life.”
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Cosmetic surgery, Prozac, Ritalin, Viagra, and Botox are all potential examples. His work provides a way of explaining the complicated feelings that antidepressants stir up for us, both as individuals and collectively.

Elliott argues that enhancement technologies fascinate and aggravate us because they alert us to a contradiction in our national value system. On the one hand, America prizes success, and life here is organized around the heated pursuit of it. America is a democracy with a high degree of social mobility; we’re all searching for anything that might give us a competitive edge over our neighbors. (We are also, most likely, looking over our shoulders at whatever our neighbors might be using to get ahead, simultaneously judging them for using it, and wondering where we can get some ourselves.) On the other hand, Americans are also devoted to the idea of personal authenticity. We believe it’s important to be our “real” selves and are ever fearful of losing touch with our inmost natures in the push of worldly ambition. Self-discovery and self-actualization aren’t just enjoyable activities; they’re social demands. In America, Elliott believes, we tend to think of life as a never-ending process of figuring out “who we are” and then striving to live in such a way that we can enact the interests and proclivities that make us unique. This focus on the self as a guiding principle may partly stem from the secular nature of our society. In America since the late nineteenth century, Elliott writes, “finding yourself has replaced finding God.”
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Being who we really are is nothing short of a moral imperative—maybe the strongest one we modern Americans have.