Fuse Book Review: Peter Kramer’s Fight for Optimism about Antidepressants
In this book, Peter D. Kramer counters what he sees as an ill-informed and dangerous backlash against antidepressant medications.
Ordinarily Well: The Case for Antidepressants by Peter D. Kramer. Farrar, Straus and Giroux, 336 pages, $27.
Peter Kramer’s new book is timely and well-argued, in effect doubling down on the case he made for antidepressants in his Listening to Prozac (1993). What brings him to another book-length treatment of the subject is the aim of countering what he sees as an ill-informed and dangerous backlash against the medications. But before we get into his methods or conclusions, I want to stress something that is too little acknowledged about Peter Kramer, namely, that he is a writer, in the fullest sense, and maybe, in some sense, first and foremost.
That he has fine expository style we know from Listening to Prozac, where he fused findings in neuroscience to his experience in clinical practice so as to mark a turning point in the way we think about ourselves. The expository gift is evident, as well, for example, in his Freud: Inventor of the Modern Mind (2006). In it he retells the Freud saga not from the renowned analyst’s point of view, and not by debating theory with him, but by drawing on the accounts of those Freud analyzed, which leads to a fairly conclusive dethronement.
But what you might not know — and what I mean by calling him a writer in the fullest sense — is that he is also a novelist. You might not know it because Kramer, who has been credited with keenness in diagnosing and to some degree shaping the zeitgeist, got the timing all wrong when his novel Spectacular Happiness came out in July, 2001. The novel centers on a terrorist. Chip Samuels is an eco-terrorist, to be sure, a reader and a writer, a devoted father, and, very much to the point, a passionate swimmer. He lives in the fictional town of Sesuit on Cape Cod and aspires to rid it of the ostentatious dwellings that mark private stretches of beach and keep swimmers from the sea.
Take, for example, the Giampiccolo house, a “monstrous mock-Victorian, a seaside abomination.” Chip feels that the “house spoke” to him, “asking to be destroyed.” The act of destruction — of fastidious disassembly — wrought by Chip and his co-conspirator Sukey, is captured on a video that shows the Giampiccolo monstrosity “slumping ignominiously to earth, like a condemned Atlantic City hotel.” That video gives Chip and Sukey’s micro-group FtB — Free the Beaches — national cachet. No one gets hurt, in FtB’s various and increasingly acclaimed architectural deconstructions; there’s never arson or injury involved, the sort of thing that Chip believes has given terrorism a justifiably bad name. Sukey’s work as a realtor helps keep FtB informed about who will be on site and when.
Spectacular Happiness is an elegant meditation on class, fatherhood, marriage, and swimming. The likes of Zola, Dickens, Conrad and Marx are referenced — Chip much prefers the afore-mentioned novelists to the dialectical materialist — without weighing down the plot, in some way fueling it. Perhaps this is the time for the novel to get the readership it deserves, which it was deprived of by a head-on collision with history. Spectacular Happiness came out shortly before 9/11, an event that made any positive appraisal, however wry or humorous, of any sort of terrorism, close to unimaginable. How many readers, after the attack, might enjoy a sneaking appreciation of a line like: “I felt compelled to sit in a neighbor’s house and discover a fit means of destruction, the performative equivalent of the mot juste.”
I’m not delving into the thwarted fate of Spectacular Happiness just to praise it, much as I like revisiting it, but because the main character represents a side of Peter Kramer you may have a hard time reconciling with the author you know from Listening to Prozac. Chip Samuels, the novel’s main character and narrator, disapproves of antidepressants as forcefully as the Kramer of Listening to Prozac, challenging himself all the way, winds up welcoming them. It’s as if Kramer had poured all his caution and hesitation about the new class of medications into Chip’s reaction to their effect on Anais, his wife.
Anais had been something of an intellectual mentor to Chip, introducing him to the fine points of Situationism, the body of French thought that critiques both capitalism’s need for spectacles and the left’s response to them. But suddenly she decides all her sophisticated theorizing only disguised irreducible depression. Chip is appalled to see her “hypnotized, by therapists and pill-pushers,” pulled toward “what until recently she had variously called Disney happiness, Nintendo happiness, Gap happiness.” He fantasizes about hiding her meds for a bit, in the hope of being “blessed with one of her old political rants.” Instead, he hears himself accused by Anais “of being covertly and chronically depressed … stranded self-righteously in the sixties.”
The worst of it concerns their son Hank. Anais approves of Hank’s being put on Ritalin so as to jump start what the principal of his elementary school deems Hank’s too skittish approach to reading. When Anais disappears for one summer, as she is wont, Hank, left with his father, swims a lot, and when not swimming, Ritalin free, and without parental prodding, chooses to read voraciously.
It’s hard to think of a more resounding refutation of Peter Kramer than Chip Samuels, or a more take-no-prisoners assault on Listening to Prozac than Spectacular Happiness. This makes it all the more notable that in Ordinarily Well Kramer takes pains to thoroughly engage and rebut Chip’s point of view. When I emailed Kramer to ask why, after the qualms expressed so forcefully in his novel, he would once again so ardently defend antidepressants, he replied, “I am ambivalent about the drugs’ use, but I also consider it outrageous, wrong, wrongheaded, and dangerous to say they don’t work.”
Kramer’s outrage at those who misuse statistical methods to debunk antidepressants comes through abundantly in his new book, a good part of which consists of strenuous discussion and dissection of meta-analyses randomized control trials, and other tools of evidence-based medicine. Kramer refers to evidence-based medicine as, “a two-decade-old movement that, in its extreme form, foresaw a future in which doctors would dispense with clinical wisdom and relay almost exclusively on the results of highly structured experiments.”
Kramer does not oppose this approach in principle, far from. He credits EBM as the “motive force” in bringing antidepressants to bear on cases of dysthemia, or low-level depression. What makes him bristle is the sort of positivist fanaticism that came with the elaboration of EBM, the doctrine that the lessons learned from the face-to-face encounters of psycho-therapy should be junked, and that results from randomized controlled clinical trials should serve as the sole guide to treatment. Though he doesn’t say so in so many words — that’s not his style — you get the feeling that when Kramer confronts the more uncompromising versions of this doctrine he’s saying to himself: Don’t make me laugh.
Kramer names dual influences on his medical practice — “rigorous trials and clinical encounters.” Ordinarily Well allots space to both. Chapters on EBM and statistical methods, including detailed analyses of how the latter have been misused, alternate with what he calls Interludes, in which he discusses clinical practice.
The book, in fact, begins with a decisive event that unifies these approaches. A close friend, and fellow therapist, suffers a stroke and emerges with impairments that make it unclear if he could resume work or even live “outside a nursing home.” Scouring the medical literature, Kramer finds controlled trials in which placebos are matched with Prozac in the treatment of stroke victims. “Three months down the road,” he writes, “[stroke] patients on Prozac had recovered much more their arm and leg movement than had the patients on placebo. Those given… the antidepressant were more likely to be living independently … In the wake of stroke, antidepressants prevent depression and preserve the ability to think clearly.”
Kramer then learns that the neurologist in charge of his friend’s care, presumably, like most practitioners, an advocate of EBM, decided, nevertheless, not to prescribe an antidepressant because he “understood they were little better than placebos.” Kramer knew the backlash against antidepressants had spokespeople high up in the world of medicine, including Marcia Angell, ex-editor in chief of the New England Journal of Medicine, and Irving Kirsch, author of Listening to Prozac but Hearing Placebo: A Meta-analysis of Antidepressant Medication. But he may not have appreciated fully, until his friend’s stroke, how far into medicine this backlash reached.
It’s impossible to finish Ordinarily Well with a high regard for the magical placebo: attempts to equate its powers with those of antidepressants prove in every case to be flawed if not polemical or even mischievous. The placebo turns out to be nothing. Antidepressants, though, are something, and work, reasonably well.
The book ends on a well-reasoned and somewhat contagious note of optimism. Kramer writes:
Think of the difference between practicing in the course of my career and practicing in other eras — any, besides that heady one when modern psychotherapeutic drugs first came into use. To get to meet Prozac and then to work in concert — what unexpected reach, for a clinician trained exclusively, all but exclusively, in psychotherapy. I am conscious of the privilege.