Listening to Prozac by Dr. Kramer

First published in 1993, "Listening to Prozac" by Dr. Kramer contains the origin of the term "cosmetic pharmacology." It is derived from Kramer ascertaining the future sub-clinical use of SSRI antidepressants like Prozac in the general population. That is, based on his experience with Prozac with his clinically-diagnosed patients, he argues that individuals without any serious psychiatric problems could benefit from the use of the drug.

Kramer refers to case reports of patients of his that were either not responsive or minimally responsive with traditional psychotherapy, but upon treatment with Prozac underwent transcendental metamorphoses that alleviated their clinical symptoms. In addition, a number of these patients purportedly felt "better than well" and aspects of their lives completely independent of those being psychiatrically treated were bettered. Kramer attributes some of the effects of Prozac to it altering the neural substrate of personality, which traditionally has been (strangely) considered outside of the domain and capability of psychopharmacology.

I personally am very skeptical of the widespread use of SSRI's under the umbrella term of cosmetic pharmacology. As we shall address in the future, their popularization and ubiquity is a result of being firmly pushed by large pharmaceutical companies with mass marketing campaigns for both individual patients (TV ads) and medical professionals (free food, insurance benefits, etc. by catering via pharmaceutical representatives). At first glance I immediately dismissed concerns over this as conspiracy theories. However, Dr. Breggin, possibly the most direct counterpoint to Kramer, draws attention in his works (I read The Antidepressant Fact Book, but his related popular work is Talking back to Prozac) to how the majority of all the basic clinical research done on SSRI's and Prozac in particular are in serious question. Suicides are written off under "depression not cured" and not reported. Participant pools have weeded out individuals unlikely to give favorable data for the drugs. The double-blind portion of a number of the studies is easily broken via the identification of well-known side effects of SSRIs. In short, there have been a number of violations of both scientific ethics as well as the basic principles of the scientific method. In addition to concerns over the basic research, there is very little long-term data on the safety and efficacy of SSRIs. Contrary to popular belief, just because something has "been around for a long time" (here, only a few decades) or just because "a billion people have taken something" doesn't mean a drug is safe or efficacious. In a nutshell, a plethora of work is necessitated before SSRIs can be considered safe for clinical pathologies, let alone as cosmetic pharmaceutical agents. However, I don't think this means they aren't good candidates for cosmetic pharmacology; the data just isn't there yet to ascertain one way or the other.

Despite my skepticism over SSRIs as cosmetic pharmaceutics, Kramer paves a lot of philosophical groundwork for this emerging concept. He ties in his SSRI treatments with Dr. Mark Sullivan's suggestion that patient autonomy is the ethical yardstick to replace the contemporary standard of risk-to-benefit ratio. Kramer writes "In judging whether the use of a medicine is for good or ill, Sullivan proposes we ask whether it promotes or retards a person's capacity to run his or her own life. An addicting drug may make a well person happier, but, by virtue of the compulsion inherent in addiction, it compromises autonomy. Illness also compromises autonomy, so an addicting drug might be used in the treatment of illness and on balance meet the ethical guideline. The standard of autonomy makes us rethink what our objections might be to a mood brightener, a drug that is by definition not addicting." (p. 256)

I believe the above excerpt applies as well to cosmetic pharmacology as it does to contemporary medicine, in no small part due to the lack of a good alternative yardstick of efficacy. The majority of workings of the brain are still an enigma to modern science, the mechanistic fashion with which antidepressants specifically "work" foremost in relation to the current discussion. Because of this, brain imaging technologies and neurochemical analyses cannot yet prove sufficiently guiding in ascertaining whether or not a pharmaceutical is "working" for a patient. We therefore have to substitute the absurdly crude and arbitrary criteria of the DSM-IV and similar clinical evaluation tests to guide medical treatments. This notion of autonomy as an ethical yardstick partially resolves these "shooting in the dark" attempts to ascertain the efficacy of pharmaceuticals. While still crude and abstract, it seems to me a more concretely positive criterion than the aforementioned ones. Combined with sufficient clinical data for the efficacy and safety of pharmaceuticals, I hope that this concept of autonomy receives greater focus when applied to candidate cosmetic pharmaceutics.

"Listening to Prozac" is a great place to start with regard to exploring the topic of cosmetic pharmacology. It identifies well the potential scope of pharmaceutics' ability to alter a wide array of individual attributes both within and outside clinical pathology and addresses the knee-jerk reaction that "cosmetic pharmacology" evokes in within the medical ethics status quo. It also provides guidelines for evaluating cosmetic pharmaceutics and less explicitly (perhaps indirectly) illuminates how we should be more critical of candidate cosmetic pharmaceutics with regard to efficacy, safety, and how research data regarding them is acquired to ensure high quality and lack of bias.