By Peter D. Kramer Farrar, Straus and Giroux, 2016 Review by Elizabeth A. Throop, Ph.D., on Sep 6th 2016
In Ordinarily Well: The Case for Antidepressants, psychiatrist Peter D. Kramer presents an exhaustively researched history of the development of antidepressants. Tracing the beginnings of antidepressants in 1950s Switzerland and bringing us to the present day, Kramer intersperses a close examination of drug trials and the scientific method with personal reminiscences and tales from his own practice. He concludes, not at all surprisingly, that antidepressants are profoundly life-changing for a wide variety of people.
Kramer begins by confessing that, during his medical training and for the early part of his career, he did not believe that psychotropic drugs would ever have efficacy superior to psychotherapy. He was convinced in the 1970s that psychoanalytic psychotherapy was the only treatment available for depression and other life difficulties. At the same time, he tells us, he was keenly aware of the depth and chronicity of life-long depression, finding himself frustrated at being unable to help the most depressed patients. So Kramer slowly began incorporating imipradine—the then-available antidepressant—into his treatment regimes, and he has continued to prescribe a variety of antidepressant drugs. He tells us that he does not see "end-stage" depression, and neither do his colleagues, of the kind that was much more prevalent fifty years ago (p. 37), in part because depressive symptoms are treated much earlier, with highly effective drugs (p. 39).
Kramer describes the testing of these drugs in great detail, outlining, and criticizing, the differences between drug trials conducted and/or monitored by the Federal Drug Administration, university researchers, and pharmacological companies. He saves his harshest words for Big Pharma's testing of psychotropic drugs, describing a drug trial conducted in St. Louis involving "volunteers" who largely were the poor and dispossessed caught in a cycle of relapse. Kramer (who did ethnographic-like research at the drug trial facility) describes the rich social interaction provided to the volunteers, whose lives are otherwise difficult (in part because of their depression), along with the antidepressants. He is troubled by this:
Once a study is over, they will not be able to afford the medicine that helped them, or it may be unavailable. These patients will relapse and then be candidates for future trials. If they haven't relapsed, it might be in their best interest to make out that they have (p. 141).
Kramer's passion comes through most strongly in his discussion of Big Pharma drug testing, seeing it, rightly I think, as exploitative and ethically and scientifically questionable (p. 214). "Why is affordable, competent care not widely available for the most treatable of mental illnesses, depression?" he asks (p. 145). It is not a question he tries to answer, unfortunately. Kramer's larger point avoids single-payer health care.
Kramer seems to believe (without providing any real evidence) that there is an anti-antidepressant lobby; he cites a few newspaper articles that either describe research critical of psychotropic medicine or tell stories of people whose use of antidepressants led to tragedies or difficulties of one kind or another. From these occasional news stories, Kramer apparently concludes that there is a widespread belief in the United States that antidepressants are bad.
There really is no evidence for that conclusion, however, and Kramer doesn't recognize his contradictory positions. For instance, he argues at p. 39 that end-stage depression has all but disappeared due to antidepressants, while he complains at p. 173 that there is a raft of anti-antidepressants articles in the mainstream media; he seems to think that those news stories influence people away from using antidepressants. Now, either people are getting better because of antidepressants, in part because they are being treated earlier, before the depression has become chronic, or people are avoiding the use of antidepressants (in which case we'd be seeing more chronicity). In other words, Kramer's impetus for this book, however well written and researched (at least in parts) it may be, is opaque. His intended audience is equally unclear.
My informal and thoroughly unscientific survey of psychologists of my acquaintance indicates that Kramer's premise is exactly wrong. That is, there is little to no stigma attached to taking antidepressants in this country, USA Today headlines notwithstanding. Indeed, though I am not a consumer of psychotropic drugs, whether antidepressants or antianxiety medicines, almost everyone I know is. And, while I remain unconvinced that depression, anxiety, and many other troubling behaviors are solely biologically based (as the doctors seem to), I also remain unconvinced that Kramer's assertions about media treatment of antidepressants are accurate. Kramer hardly addresses culture at all in this book. I wouldn't expect him to; he is not a cultural anthropologist and does not understand how embedded he is in a culture that individualizes suffering in the way that United States culture does.
Kramer's book is accessible and well documented, written in a lively and engaging style, but it is based on his hyper-sensitive reaction to critical media treatment of antidepressants and other psychotropic drugs. It is unclear why and for whom he wrote this book. It does not seem to be answering a burning societal question, though Kramer most certainly is a talented writer. If a reader is consumed by a wish to understand the development of antidepressants, however, Ordinarily Well is the book to read.