November 15, 1993 12:00 PM

When the drug Prozac was first introduced nearly six years ago, it was hailed as a miracle cure for depression. Since then, some 5 million Americans have used the medication and found more than just relief from gloom. Some have become more confident, optimistic and assertive as well. Which raises some troubling questions: Can one’s essential nature be changed by swallowing a pill? And, if so, is our society heading toward a time when people will use drugs not just to treat illness but to re-engineer their personalities?

Peter D. Kramer, 45, associate clinical professor of psychiatry at Brown University, has treated many patients with Prozac in his private practice in Providence. In his best-selling book, Listening to Prozac (Viking), he chronicles the wondrous transformations he has witnessed. For Kramer—who has never taken any antidepressant—the changes were so profound they led him to re-examine what constitutes the self “Are we just a sack of chemicals,” he asks, “or do we have souls?” A native of New York City who received his M.D. from Harvard, Kramer—who lives in Providence with his wife, Rachel Schwartz, 43, a public-health researcher, and their three children, Sarah, 12, Jacob, 9, and Matthew, 3—recently spoke with Boston bureau chief S. Avery Brown.

How does Prozac work?

Prozac is one of a new generation of antidepressants. It is the first drug designed to treat depression by affecting only one system in the brain—the pathways that use a chemical called serotonin as the transmitter. Prozac slows the uptake of serotonin so that the chemical sits in the synapse—the space between nerve cells—longer. That makes communication between nerve cells more efficient. Beyond that, I don’t think anyone knows exactly how Prozac changes a patient.

What are the side effects?

People don’t have the dry mouth, constipation, rapid heartbeat and all the side effects associated with earlier antidepressants. Prozac can cause mild nausea and headaches that occasionally fade with lime. One long-term side effect is sexual dysfunction or loss of sexual interest, which may occur in as many as a third of patients.

What about earlier reports of Prozac patients committing suicide?

I think there may be four or five ways that Prozac can make people more suicidal—by causing mental or physical agitation and so on. But these many causes add up to few cases. Many of the claims made in the most highly publicized cases involved misrepresentations that were later exposed in court. In my book I mention a case in which someone attempted suicide on Prozac and then got well on a not very different medicine. It was the only case like that I’ve seen. But it must be said that some depressed people do attempt suicide.

How have your patients responded to Prozac?

A third of the people don’t respond at all, but a substantial number may respond in important ways. In the book I talk about Tess, a successful businesswoman who, after a difficult childhood, found herself in one degrading relationship after another and was becoming increasingly lethargic and unhappy. While before she was in mourning over an unsuccessful relationship, after she started taking Prozac she had three dates a weekend. Some patients told me they had always wondered about what people meant when they talked about passion or enthusiasm. Then, all of a sudden, on Prozac, they “got it.” They felt they had found their true selves.

But others feel sort of numbed on the medication. Some have said they feel less troubled but also less responsive to their world. One of my patients, Sam, an architect, felt he had fewer rough edges. Although he was less obsessed with work, his quirkiness and inclination toward sarcasm vanished—and he considered that a loss.

Has Prozac changed basic assumptions about the cause of depression?

We are now in a period where people tend to attribute many things to genetics and brain biology. There has long been tension between people in the field of psychology who believe the trauma of childhood can be reversed by thinking or talking about it and those who believe the trauma may be reversed simply by taking medication. I think having Prozac around accelerated the biological movement.

Does Prozac eliminate the need for psychotherapy?

Psychotherapy is an enormously important tool for treating mental disorder, especially the conditions that Prozac is helpful in treating—the early stages of depression, its less serious and more common forms. I don’t advocate use of Prozac over an extended period. I usually try to get people off at six to nine months; with more depressed people, I prescribe the drug for a longer period. But some patients taken off the medication early want to go back on. I might also mention that for the severely depressed some of the older antidepressants might be more effective.

Is there a risk that Prozac may be used as a kind of happy pill?

We have a technology that arrived before there’s any consensus about how to use it. If we do have a medicine that can change self-esteem, we’re still left with the question of whether that medicine should be used for that purpose. Prozac gives some people the traits that society demands today—assertiveness, self-confidence, optimism—and that is a little worrisome. We don’t want a society where only one temperament is rewarded.

Do you see this happening already?

I see it in a more general sense, not just with Prozac. There is a tremendous emphasis on assertiveness in our society, as if that were a universal virtue. But I come to this with the old theory of life, where the challenge is playing the hand you are dealt. I think we need diverse groups. We should be able to find good use for people who are sentimental, shy or sensitive rather than having to put them on medicine.

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