Tuesday, May 31, 2016

Before Prozac

Back in the day psychiatrist Peter Kramer authored a book called Listening to Prozac. In it he touted the virtues of the new antidepressant medication, going so far as suggesting that Prozac could make you a new person, could make you into something else.

Kramer seems to have allowed his enthusiasm to get the better of him. While Prozac and the other SSRIs are effective for many people, they have become overprescribed by primary care physicians to patients who have bought the hype about Prozac.

Now, Kramer is making a more modest claim. He has completed a study that has shown that Prozac is effective for patients who are deeply depressed.

In reference to crippling melancholic depression, he writes:

In much of the country, antidepressants had gained acceptance. In time, I learned to supplement talk therapy with prescribing. Nowhere did I see the volume of end-stage depression I had previously encountered, nor have I ever again. During 30-plus years of outpatient practice in Providence, R.I., none of my patients has begun with or, to my knowledge, moved on to paralyzing melancholy.

One recalls the young woman in the Netherlands who was allowed to commit suicide—that is, was put to death—because the authorities felt that her depression was intractable and permanent.

But that is not the reason I am bring up this issue. Kramer makes another striking observation that is worthy of some attention. When he did a psychiatry rotation at Harvard Medical School in the late 1970s, the department was run by a psychoanalyst. And psychoanalysts at the time did not believe in anti-depressants.

Prozac did not exist but antidepressants like Anafranil, Tofranil and MAO inhibitors were available and fairly widely prescribed.

American psychoanalysts in hospital settings refused to give them to their patients. Kramer recounts his experience:

I trained at Harvard Medical School, a center of American psychoanalysis. Antidepressants had been available since the late 1950s, but to prescribe them was considered a failure of imagination. Psychiatrists believed that the drugs robbed patients of their autonomy.

For my psychiatry rotation, I was sent to a hospital staffed by eminent psychoanalysts. The ward housed many patients like Irma. In the activity room, depleted depressives sat still, distinguishable from catatonic patients only by their hand-wringing. We offered psychotherapy. Otherwise, depression was allowed to run its course.

Today, such dereliction would be considered to be malpractice.

I note that a few years earlier I myself worked in a psychiatric clinic in France that was run by people who had trained in psychoanalysis. Who had trained with Jacques Lacan, as it happened. As long as antidepressants had been available, these psychiatrists had prescribed them. They never deprived their patients of effective treatments. And yet, they knew about the clinical ineffectiveness of psychoanalysis and did not allow anyone to offer it to a psychotic or depressed patient.

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