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.
No comments:
Post a Comment