I just finished 'Listening to Prozac' by Peter. D. Kramer (psychiatrist).

http://www.amazon.com/Listening-Proz.../dp/0140266712

After reading some reviews I expected to find a book high on rhetoric and rather naieve and unrealistically optimistic about virtues of pharmaceuticals. Instead I found a fairly balanced analysis of some of the goods and ills that are likely to follow the observation (however rare) that some people undergo a characterological change on a medication by becoming "better than well".

Kramer makes it clear right at the start of the book that he is going to focus exclusively on case examples where people responded to Prozac by becoming 'better than well'. As such, he makes no mention of 'non-responders', 'mild-responders', side effects, or withdrawal syndromes - as this is beyond the scope of his present concern. I think that this fact has been often missed by his critics and equally by his supporters when people accuse him of presenting Prozac as a cure-all wonder-drug. Kramer's concern is around ethical issues on prescribing cure-all wonder-drugs - whether Prozac is one in fact or not that doesn't undermine his analysis of the ethical issues. If one is optimistic about more selective and effective pharmaceuticals in the future that only makes his ethical concerns even more important to sort out.

In reading the book one might be inclined to attmept to obtain some Prozac - especially in the initial stages of the book. Because the focus is exclusively (and artificially) on the successful cases Prozac starts to look like a wonder-drug indeed. People who were socially shy become outgoing and vivacious. People who are unable to stand up for themselves become more assertive. People who are anxious, inhibited, afraid of rejection or loss become more resilient and able to seek out meaningful connections and relationships with others.

Kramer then launches into a discussion of how our present society values such traits as individualism, independence, assertiveness, and so forth. If we grant that Prozac is able to effect such temperamental changes (for the sake of argument) then whether those temperamental changes are considered an 'improvement' or not is going to depend on what kind of temperament society values. If people had responded similarly to a medication in victorian society these characterological changes would have been regarded as harmful side-effects. In a present society they are valued such that the characterological changes lead to us describing these people as 'better than well'.

Kramer draws our attention to interesting issues around whether drugs able to provide these effects should be available to everyone or whether they should be restricted to people who are severely restricted in their functioning. Here he becomes much more controversial drawing an analogy between epilepsy and 'kindling' and depression. The notion here is that if you stimulate part of a dogs brain it will not be effected. If you repeatedly stimulate that same part then you will induce a seizure. If you repeatedly stimulate (inducing seizures) then eventually the dog will have seizures when you aren't stimulating. The notion is that over time the dogs brain becomes more sensitive. He maintains that a low level background blandness or dysthymia or dissatisfaction might eventually kindle severe depressive episodes and that medication such as Prozac might disrupt that kindling process thus making people more resilient to developing depression in later years.

This part of his book is the most controversial. Critics maintain that the presence of SSRI's (or other drugs affecting the serotonin system) are what result in the kindling effect. This part of the book is important, however, for his idea that Prozac (or drugs that have the ability to alter temperament in a way that society deems "better than well") should be freely available. If this part doesn't work out then that justification would seem to be lacking. Kramer does acknowledge there to be ethical issues in changing peoples character in accordance with current social preferences, however. He raises interesting issues even if his conclusions are somewhat hampered by his overly focusing on successful cases. Still, even if Prozac isn't quite the wonder-drug as he has portrayed it as being one might think that future drugs will be and thus the ethical issues he raises even if not applicable to Prozac, could be important for future developments in pharmacology