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Can there be a ‘cosmetic’ psychopharmacology? prozac unplugged: the search for an ontologically distinct cosmetic psychopharmacology

Blackwell Science, LtdOxford, UKNUPNursing Philosophy1466-7681Blackwell Publishing Ltd 2005 200562131143Original articleProzac UnpluggedPamela Bjorklund Can there be a ‘cosmetic’ psychopharmacology? Prozac unplugged: the search for an ontologically distinctcosmetic psychopharmacology Pamela Bjorklund RN MS CS PMHNP
Assistant Professor, Department of Nursing, The College of St. Scholastica, Duluth, MN, USA Abstract
‘Cosmetic psychopharmacology’ is a term coined by Peter Kramer inhis 1993 best-seller, Listening to Prozac. It has come to refer to the useof psychoactive substances to effect changes in function for conditionsthat are either normal or subclinical variants. In this paper, I ask:What distinguishes an existential ailment from clinical depression, oreither of those from normal depressed mood, melancholic tempera-ment, dysthymia or other depressive disorders? Can we reliably distin-guish one from the other? Are the boundaries of illness and disorderreally so distinct? If not, how can we know that treatment of ‘depres-sion’ with Prozac in any given instance constitutes a cosmetic asopposed to, say, a medical or clinical use of psychopharmacology – adistinction that seems to turn on our ability to clearly differentiate theclinical from the cosmetic. If we cannot reliably distinguish betweensuch conditions, can we even have a cosmetic psychopharmacologythat is not a form of malpractice, broadly speaking? What if weunplugged Prozac from all the amplitude and hype that resulted inListening to Prozac becoming an instant best-seller and simply askedwhether or not we can clearly distinguish an appropriate cosmetic useof Prozac for ‘depression’ from an inappropriate cosmetic use ofProzac, and both of those from Prozac’s appropriate clinical, that is,non-cosmetic uses? If we cannot make these distinctions, perhaps itis too early to say there can be such a thing as a cosmeticpsychopharmacology.
cosmetic psychopharmacology, Prozac, depression, Correspondence: Pamela Bjorklund, Department of Nursing, The College of St. Scholastica, 1200 Kenwood Avenue, Duluth, Minnesota 55811-4199, USA. Tel.: +218 723 66 24; fax: +218 723 64 72; e-mail: Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
his much-praised, and much-maligned,1 1993 best- Introduction
seller, Listening to Prozac. It is his ‘mnemonic’ for If a patient is not tearful, inappropriately guilty, having trou- what he observed as Prozac’s effect in transforming ble concentrating, losing sleep, losing weight, thinking about the selves of even non-depressed individuals – leaving death or suicide – in short, if she is not clinically depressed them ‘better than well’ and more ‘socially attractive’ – yet she responds to an antidepressant, then what exactly (Kramer, 1993; p. xvi). In Elliott’s (2004) words, is that antidepressant treating? A personality disorder? ‘[Kramer] was referring to the way psychoactive Unhappiness? Existential dread? . . . What if Prozac does, in drugs could be used not just to treat illnesses but to fact, treat existential ailments? What if it really does make improve a person’s psychic well-being . . . [to move] a a person feel less alienated, less fearful of death, more at person from one normal state to another’ (p. 1). To home in the world, more certain about how to live a life? Is summarize, the term has come to refer to the use of psychoactive substances like Prozac to effect changes The Last Physician: Walker Percy & the Moral Life of Med- in function for conditions that are either normal or subclinical variants (Sperry & Prosen, 1998). These are conditions, in other words, that are either clearly Carl Elliott asks a good question: What, indeed, not medical conditions – rather, are spiritual or exis- would be wrong with that? Apart from issues of mal- tential conditions, or perhaps are merely part of the practice perhaps, at least in some cases, what is wrong human condition – or that might turn out to be med- with prescribing an antidepressant for someone who ical but are still too subtle to detect as existing med- is not depressed but rather is merely – as if this were ical conditions, or that might turn out to be medical not difficult enough – alienated, fearful of death, ill once a sufficiently advanced biomedicine can locate at ease in the world and uncertain of the purpose in life? Certainly, some of what is wrong is that this sort What might be wrong with prescribing Prozac, or of ‘existential ailment’, whether spiritual, rooted in any of the other new- or old-generation antidepres- biology, or both, is part of the human condition. To sants,2 for an existential ailment is an important and exist as a human being is to have the capacity to intriguing philosophical question – and it begs many question the meaning and purpose of life, and to know and fear the inevitability of death. This is not 1Elliott (2000) calls it a ‘splendid book’ (p. 8) while Rothman disease or disorder. This is a reasonable, natural, (1994) writes: ‘Were Listening to Prozac a package insert, it expectable, normal, if you will, response to shifts in would never get FDA approval . . . To the extent that Kramer is frameworks of meaning, or to problematic social con- typical of his generation of physicians, it is plain that trusting the ditions in troubled times: ‘Some kinds of responses to medical profession to be strict gatekeepers before therapies, the world are reasonable even when they are new or otherwise, is foolhardy. Anybody who expects physicians disturbing . . . . For all the good that antidepressants to save us from ourselves, or from the worst imaginable abuses do, there remains the nagging suspicion that many of of twenty-first century medical interventions . . . had better start the things they treat are in fact a perfectly sensible searching for alternatives’ (p. 34).
response to the strange times in which we live’ 2To treat depressive disorders, we now have a long list of new- and old-generation antidepressant medications, including the Here and elsewhere, Elliott (1999a, 1999b, 2000, selective serotonin reuptake inhibitors (SSRIs), the norepineph- 2003, 2004), who is a bioethicist, expresses his con- rine dopamine reuptake inhibitors (NDRIs), the selective cerns about the medicalization of human unhappi- serotonin norepinephrine reuptake inhibitors (SNRIs), the sero- ness, an insidious development implicit even in tonin-2 antagonists/reuptake inhibitors (SARIs), the noradren- Elliott’s use of the term ‘existential ailment’, and ergic/specific serotonergic antidepressants (NaSSAs), the non- about the implications of a cosmetic psychopharma- selective cyclic antidepressants (including tricyclics, tetracyclics cology to treat it. ‘Cosmetic psychopharmacology’ is and dibenzoxazepine), the irreversible monoamine oxidase a term coined by Peter Kramer in the introduction to inhibitors (MAOIs) and the reversible inhibitor of MAO-A Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
others. First of all, no one seriously questions the So, here are the questions that concern me: What appropriateness of treating clinical depression with distinguishes an existential ailment from clinical Prozac. ‘Major depression can be lethal’, writes depression – or either of those from depressed mood, Elliott (1999a). ‘Up to 15 percent of patients who alienation, melancholia, dysthymia, or other depres- have major depression commit suicide. For such peo- sive disorders? (This is not so simple a question as it ple, antidepressants can be lifesaving’. Obviously, he first seems.) Can we reliably distinguish one from the is not concerned about the use of antidepressants by other? Are the boundaries of illness and disorder those people. What worries him about Prozac is not really so distinct? If not, how can we know that treat- its use to treat ‘illnesses’ per se, but rather the possi- ment of ‘depression’ with Prozac in any given instance bility that the ‘ills’ for which Prozac is so often pre- constitutes a cosmetic as opposed to, say, a medical scribed are ‘part and parcel of the lonely, forgetful, or clinical use of psychopharmacology? In other unbearably sad place where we live’ (Elliott, 2000; p.
words, how would we know a cosmetic psychophar- 8). If so, then something important is lost when we macology when we saw one? Is it anything other than try to medicate away such distress. It is to this Wyatt- inappropriate prescriptive practice, meaning it falls Brown (1999) refers when he notes (in Inherited outside the boundaries of the current accepted psy- Depression, Medicine, and Illness in Walker Percy’s Art) that ‘pain and ordeal had their indispensable Whether an antidepressant is used clinically or cos- uses’ (p. 116) and that ‘Dostoevsky taught . . . that metically seems to turn on our ability to clearly dif- [existential] “suffering is an evil, yet . . . through the ferentiate the clinical from the cosmetic, that is, to ordeal of suffering one gets these strange benefits of differentiate normal depressed mood and the existen- lucidity, of seeing things afresh” ’ (Percy 1985; p.
tial ailments that can produce such moods – along 116). It is fair and accurate to say that Prozac has with, say, bad marriages and stressful jobs – not only both legitimate and illegitimate uses. Determining from melancholic temperament but also from clinical which is which and what is cosmesis and what is med- depression, dysthymia and the depressed mood that ical treatment (or is cosmesis now the same as accompanies so many other appropriately diagnosed medical treatment?) has become quite problematic, psychiatric disorders.3 If we cannot reliably distin- at least for some philosophers and psychiatrists.
guish between such conditions, and thereby deter- Clearly, in order to say that a cosmetic psychophar- mine whether an antidepressant is medically macology exists, or is even a legitimate possibility, indicated or not, can we even have a cosmetic psy- those who use Prozac to treat disease and disorder chopharmacology – defined as a psychopharmacol- must be able to distinguish between the ‘ills’ that are ogy for normal variants that uses Prozac to, e.g. ‘help part and parcel of our unbearably sad world – for which the prescription of Prozac then becomes a 3Depressed mood can be symptomatic, e.g. of the personality cosmetic psychopharmacology – and the medical disorders, post-traumatic stress disorder (PTSD), other anxiety ‘illness’ called clinical depression for which the pre- disorders, schizoaffective disorder, bipolar illness and substance scription of Prozac is simply an instance of applied abuse. In addition, it is hugely stressful to be mentally ill. Almost any psychiatric disorder can be accompanied by depressed mood – not to mention of course, that major depression can co- (RIMA). This does not include an equally long list of mood- occur with almost any other psychiatric diagnosis. Sorting all this stabilizing medication often used in conjunction with antide- out can be extremely complex. More often than we care to pressants to treat bipolar depression (See Bezchlibnyk-Butler & admit, there is no way to know in any given clinical instance Jeffries, 2004). ‘Prozac’ is used in this paper to denote any anti- whether treatment with an antidepressant is appropriate or not depressant available to treat a depressive ‘condition’, but partic- – except to try it and see whether a patient’s symptoms remit.
ularly those new-generation, low side-effect and high safety Despite its considerable scientific advances, this may be one of profile antidepressants, like Prozac, that ushered in the era of psychiatry’s ugly, little secrets – that so much of what it does is so-called ‘cosmetic psychopharmacology’.
Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
frazzled parents cope with their kids or to make chopharmacology cosmetic is that it moves a person chronic loners stop fearing rejection’ (Nichols, 1994; from ‘one normal, but unrewarded, state to another p. 36) – that is anything other than psychiatric mal- normal, better rewarded state’. However, if we can- practice, broadly (not legally) speaking? Certainly, a not unambiguously determine that the ‘unrewarded psychiatric practitioner who is either inexperienced, state’ from which one has been moved to that other inept or disreputable can prescribe Prozac to some- normal, ‘better rewarded state’ was, in fact, normal, one who is not clinically depressed, who does not how can we say this is an instance of cosmetic psy- have any other diagnosable psychiatric disorder, or chopharmacology? Where at least some mental states whose mood is not depressed secondary to some are concerned, including depressive states, it is occa- other appropriately diagnosed psychiatric disorder – sionally hard to distinguish between normal and someone who simply wants, e.g. to be a better sales- man (Sperry & Prosen, 1998; p. 55) or to more successfully negotiate a union contract (Kramer, Depression as normal mood or
1993; pp. 1–21). But what distinguishes a cosmetic mood disorder?
psychopharmacology of this sort from inept or uneth- ical psychiatric practice, or one lacking a scholarly How are we to tell when a depressed state is normal evidence base, which is not to say that if an evidence or abnormal, healthy or unhealthy? In fact, what do base existed for cosmetically treating ‘frazzled par- we mean when we say someone is depressed or has ents’ and ‘chronic loners’ with Prozac that such prac- depression? It seems we must know what depression is if we are to determine whether treatment of it with What if we unplugged Prozac from all the ampli- Prozac constitutes an instance of cosmetic psycho- tude and hype that resulted in Listening to Prozac pharmacology. Walter Glannon (2003a) notes that becoming a blockbusting, instant best-seller,4 and that most psychiatrists conceptualize depression, at least continues to spawn debate, and simply asked whether the more severe types that clearly constitute psychi- or not we can clearly distinguish an appropriate cos- atric illness, as a disorder of the mind arising from metic use of Prozac for ‘depression’ from an inappro- dysfunctions in the brain. He conceptualizes mind as priate cosmetic use of Prozac, and both of those from mental states generated and sustained by the brain Prozac’s appropriate clinical, that is, non-cosmetic and consisting in the capacity for cognitive states (e.g.
uses? If we cannot make these distinctions, perhaps beliefs), conscious affective states (i.e. emotions) and it is too early to say there can be such a thing as a unconscious affective states (e.g. emotional memo- cosmetic psychopharmacology. Peter Kramer (in ries) that can arouse physiologic responses when trig- Cooper, 1994) states that what makes cosmetic psy- gered by external events. Although mental states arise from brain physiology, they have a subjective 4Rothman (1994) writes that Listening to Prozac made the best- quality and representational content – i.e. they are seller lists ‘before it was so much as advertised or reviewed’ (p.
about something and are uniquely meaningful to the 34). In the Afterword to the 1997 edition, Kramer himself calls person who experiences them – that cannot be Listening to Prozac ‘more than a best-seller . . . the talk of the explained in terms of the brain alone. Glannon thus nation . . . a cultural icon’ (pp. 315–316): ‘Coverage spanned the rejects the reductive materialism that undergirds so media, including People, The Washington Post, Oprah, Good much of biological psychiatry. This perspective Morning America, and National Public Radio. At The New assumes that consciousness and other forms of men- Yorker, the book inspired one cartoon after another . . . The tality are not simply caused by neurological processes New York Times’ banner headline for its year-end summary of in the brain; rather, they simply are neurological pro- the arts was “Listening to 1993” ’ (pp. 315–316). The book made cesses and therefore can be explained entirely in Peter Kramer famous. It spawned something called ‘the Prozac terms of the material or physical structures and func- debate’ and dozens more books. Some of us are still engaged in tions of the brain: ‘But insofar as our mental states have a subjective phenomenology, and insofar as Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
their content involves features of the social and nat- chemical deviation from normal physiology? Here, ural environment, the mind cannot be explained Prozac may or may not be a necessary intervention; entirely in terms of the objective physical properties but it clearly will not be sufficient.
of the brain and body’ (Glannon, 2003a; pp. 244–245).
Psychiatric drugs . . . only treat the symptoms of mental dis- Depression, then, even the so-called clinical kind orders; they do not treat the underlying causes . . . Given the that Prozac can sometimes treat so well, is always role that beliefs and emotions play in the sequence of events more than reductive materialism would have it. It is leading to depression, [Prozac] is insufficient because ther- never simply biological, although it may be at least, apeutic intervention must also take place at the mental level or perhaps even mostly biological. Biological models in themselves are inadequate to explain or treat com- plex clinical phenomenology (Brendel, 2003a). It Nevertheless, someone is suffering; Prozac might sounds right to me that depression results not only help. It will do no good to simply wait for social from brain and body dysfunction but from mental states as well. If so, factors external to the brain must In locating depression and hence a cosmetic psy- be considered to properly diagnose and treat the dis- chopharmacology, Martin (2003) points out the order – if it is a ‘disorder’ – because, again, the mental importance of distinguishing between depression as a states that figure in its aetiology have a subjective mood and depression as a mood disorder. As a mood, quality and representational content that reflect the depression is a ‘state of low spirits, typically involving social and natural environment (Glannon, 2003a). My painful and low affect’ (p. 255). Of course, not all depression is about something; and for me it may not negative, low moods are depressions. It is ‘difficult to be about, primarily at least, a deviation from normal distinguish depression from grief, sadness, gloom, and brain physiology. In other words, a biochemical dis- a host of additional ways to feel down’ (p. 255).
turbance in neural transmission at the cellular level Depressed persons are not always sick, and depressed may be a factor in my depression, but so is the reality moods are not all bad. They can be important in con- that I live in a dangerous neighbourhood, have no job, nection with questions of value, identity and even no health insurance and no adequate childcare, do moral insight: ‘[Depressed moods] involve negative not have the resources to move to a better neighbour- evaluations of ourselves, major events in our lives, life hood, and increasingly feel helpless and worthless.
in its entirety, or the values that have been guiding Perhaps I have come to believe my situation is hope- us’ (p. 255) but can lead to a process of evaluation less. As a single mother, underemployed, poorly and revaluation that is essentially healthy.
dressed, with unmanicured hands and an old car, per- In contrast, depression as a mood disorder is by haps I feel unable to ‘approximate the currently fash- definition pathologic, even though categories of ionable ideal of the assertive, confident, resilient, mood disorder fluctuate in the Diagnostic and Statis- romantically satisfied producer and consumer’ tical Manual of Mental Disorders (DSM) (American (Parens, 2004; p. 27).5 Whether I have a diagnosable Psychiatric Association, 2000) with every edition, and mood disorder or not, might it not be normal, reason- there are many additional states of suboptimal health able and expectable to feel depressed under these in which DSM criteria are only partly met, not to circumstances? Would we then be using Prozac for mention that the notion of pathology is itself under- cosmetic purposes in medicating this ‘normal’ state? stood in terms of values – ‘the values of health and, Or, is it an ‘abnormal’ state, or only ‘abnormal’ if it indirectly, moral values that define what is culturally is, or might be accompanied by some kind of bio- acceptable’ (Martin, 2003; p. 255). Clarity about def- initions and distinctions is essential to gaining clarity 5Parens refers to Peter Kramer’s ‘abundant evidence’ (p. 27) in about what is being assessed, explained and treated Listening to Prozac that a cosmetic psychopharmacology can do with Prozac by psychiatry and psychobiology. Such exactly that – help people ‘better approximate’ currently fash- clarity is important in determining what is unhealthy or not, and in understanding the continuum between Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
health, suboptimal health and full-blown disorders.
1992). The biological psychiatrist defines disorder as Our choice of terminology reflects our attitudes: ‘If deviation from normal brain physiology (Olson, we think of negative low moods as inherently unde- 2000). The philosopher may discuss disorder as a sirable then we will tend to use the word depression moral phenomenon – an essential suffering, the result to connote sickness. If we discern value in many neg- of which one’s life falls short of being a satisfactory ative low moods we will be more likely to use the or ‘good’ life in some non-biological sense – and word depression to refer to a broad range of moods, where the appropriate treatment is that species of most of which are normal and some of which are moral education called ‘psychotherapy’ (Matthews, pathologic’ (p. 258). The term ‘cosmetic psychophar- 1999a, 1999b). The social scientist details disorder as macology’ reflects a certain attitude, too. I am just not (1) pure value concept; (2) whatever professionals sure it is an attitude based on clear ontological dis- treat; (3) statistical deviance; (4) biological disadvan- tinctions between health and illness, depressed tage; (5) distress or disability; or (6) harmful dysfunc- mood and depressive disorder, or treatment and tion. Wakefield prefers to conceptualize disorder as the latter, where ‘harmful’ is a value system based on social norms, and ‘dysfunction’ is a scientific term referring to the failure of a mental mechanism to Stretching the boundaries of illness
perform a natural function for which it was designed The boundary between health and illness has never by evolution. A mental disorder thus exists whenever been distinct. In fact, social scientists cannot agree a person’s internal mental – biological and psycholog- that there is a boundary. Are health and illness dis- ical – mechanisms fail to perform their functions as crete categories, where you either meet criteria for a designed by nature and this impinges harmfully on a disease and thus are ill, or you do not and hence are person’s well-being as defined by social values and well? Or, do health and illness exist on a continuum cultural meanings (Wakefield, 1992). The relevant where the boundary between the two is not a line but function at issue with either existential ailments or an entire region with its own indistinct borders? Here, depressive disorders is the exercise of effective health slides into illness and illness slips back into agency, which can be more or less impaired.
health almost imperceptibly such that you are not When the impairment becomes severe, the psychiatrists’ clearly ill or well until you are closer to the extremes DSM defines it as [an illness] based on sociocultural stan- of the continuum. Keyes (2002) offers a third option dards for normal or accepted behavior. But neither psychi- and conceptualizes two separate continua for mental atrists nor sociocultural standards are the final word. Insofar health and mental illness. One can be more or less as values are at stake, there is some legitimate domain healthy at the same time that one is more or less ill.
within which individuals can reasonably make their own Mental health is not merely the absence of mental assessments, according to their own values, of [illness] and illness, nor is it simply the presence of high levels of subjective well-being. Rather, mental health concep- tualized as a continuum between flourishing and lan- In other words, my melancholy may be such that a guishing is a complete state consisting of both the psychiatrist sees a harmful dysfunction (depressive relative presence of mental health symptoms and the disorder) and recommends Prozac – or does not see relative absence of mental illness symptoms. In this a harmful dysfunction, empathizes with my existen- schema, the absence of mental health (languishing) is tial plight, and puts his prescription pad away – but a risk factor for clinical depression (Keyes, 2002).
within certain limits I have some say. I am the one To make matters more complex, social scientists, who feels ill, well or something in between. I am the medical doctors and philosophers cannot agree on arbiter of my own suffering. I get to participate in the exactly what illness, or disorder is, in part because decision that my melancholy is disorder, or a normal disorder lies on the boundary between the natural response to disordered times. The question is: What world and the constructed social world (Wakefield, do we call it when neither I nor my psychiatrist is Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
sure that what I have, although I may feel decidedly Categories of illness, especially mental illness, are unwell, is an illness or a disorder, but we elect to try constantly changing; and they tend to proliferate dra- Prozac anyway? Is this cosmetic psychopharmacol- matically once new treatments hit the market (Elliott, ogy? And if we try Prozac, and it mitigates my suffer- 2004). The boundaries of any one of those shifting, ing such that my overall functioning and the quality proliferating, expanding categories remain elusive.
of my life on my own account are undeniably They depend on time, space, cultural context, land- improved, is this a cosmetic and not, or not also, a scapes of care and the particularities of individual clinical use of Prozac? (A more important question, lives (say, any given patient’s moral framework and perhaps, is whether we have done something any particular prescriber’s educational background).
‘wrong’). Perhaps I may rightfully question whether The elusive difference between treatment and this is an instance of cosmetic psychopharmacology, enhancement adds another layer of complexity: ‘Ill- which by definition involves the use of Prozac to ness and health, disability and difference, cure and move me from one normal state to another normal enhancement: it is a mistake to think there can be state, because I hardly experienced the painful and rigid distinctions here . . . [W]hat counts as an illness debilitating state from which I was moved as or a disability – or on the other hand, as normal biological variation – will . . . depend on its cultural New technologies like Prozac inevitably challenge and historical location’ (Elliott, 1999b; p. 48). My our definitions of health and illness, stretching their point, exactly. If we cannot clearly distinguish health margins and further blurring the boundaries between from illness, disability from difference, cure from normal variation (health) and pathology (illness) enhancement – and the clinical from the cosmetic – then how are we to recognize a cosmetic psychophar- macology when we see one? How are we to know Before various reproductive techniques . . . were developed, when to use Prozac, and when to, say, call a priest? infertility was simply a fact of nature; now that it can be treated, it is a medical problem. Before the invention of the lens, poor vision was simple a consequence of getting old.
A case for Prozac – or something else?
Now it is something to be treated by a medical This is how Sperry & Prosen (1998) pose the Indeed, notes Elliott, doctors now treat an array of Would you as a psychotherapist prescribe or refer for a conditions that no one considers illnesses with medication evaluation an individual who was not clinically enhancement technologies6 by which no one is partic- depressed nor even dysthymic, but requested Prozac – or ularly troubled: ‘minoxidil for baldness, estrogen for another selective serotonin reuptake inhibitor (SSRI) – postmenopausal women, cosmetic surgery for people because he believed it would make him a better salesman? unhappy with their looks, acne treatment for self- Would you prescribe or refer someone with dysthymic fea- conscious teenagers’ (p. 26). And Prozac, he might as tures who complained that her ‘depression was interfering well add, for existential angst – and obsessive-com- with my ability to meditate’? Or, would you prescribe or pulsive behaviour, shyness, separation anxiety, sexual refer for a medication evaluation someone with obvious perversion, and a whole lot more that may or may not symptoms of major depression that were in the moderate to 6Elliott (1999b) writes that the term enhancement technology Let’s say that an expert psychiatric evaluation ‘generally refers to the use of medical technologies not to cure results in no psychiatric diagnosis for the salesman or control illness and disability, but to enhance human capacities seeking to enhance his personal and professional per- and characteristics . . . [including] the use of Prozac and other sona with Prozac. He does not have a clinical, i.e.
antidepressants for shyness, a compulsive personality or low self major depression and cannot be diagnosed with dys- thymia, or minor depression; personality disorder, Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
where depression is a character trait or forms the core a philosopher like Erik Parens, in an eloquent essay of an essentially depressed self; or any other psychi- on the use of Prozac for so-called cosmetic purposes atric or medical condition for which depressed mood (Parens, 2004), to pause and pointedly, rather is so often adjunctive. He most certainly does not emphatically insert into the text: ‘Please note: have a melancholic temperament and suffers no more Kramer [referring to the author of Listening to than occasional, normal depressed mood when he Prozac] is not anxious about using Prozac to treat fails to make an important sale. He does not see him- clinical depression, nor am I’ (p. 22). There can be no self as ‘ill’, nor does his caregiver, and he wants only cosmetic psychopharmacology, it seems, at either to boost his performance as a salesman. I feel confi- dent in asserting that most expert psychiatric provid- What about in the middle? Let’s take a look at the ers would not endorse his request. Were a prescriber person with dysthymic features who complains that to offer Prozac, I suppose one could call that an her depression is interfering with her capacity to instance of cosmetic psychopharmacology, but it is meditate. By virtue of those dysthymic features, this most certainly also malpractice, broadly and poten- person is likely to be chronically depressed, irritable, tially even legally speaking. If this is cosmetic fatigued and unable to enjoy life. She may or may not psychopharmacology, then cosmetic psychopharma- have sleep or appetite disturbances, but is likely to cology cannot be a legitimate prescriptive practice. To suffer from low self-esteem and perhaps even chronic even call it cosmetic psychopharmacology is to confer feelings of worthlessness and purposelessness. Let’s some legitimacy to the practice in much the same way suppose her dysthymic features have not reached the calling a certain type of socially and medically accept- diagnostic threshold for dysthymic disorder which, able cosmetic surgery does. This is a legitimacy that it according to the DSM, is a mood disorder – a type of does not deserve. I am therefore disinclined to call clinical depression although not clinical depression this an instance of cosmetic psychopharmacology.
itself – for which there is a growing body of clinical Let’s just call it inept or substandard care.
evidence that endorses antidepressants along with Let’s turn to the person on the other side of Sperry psychotherapy as a form of treatment. Inasmuch as & Prosen’s (1998) dilemma. Here, an expert psychi- we are treating a type of clinical depression, I would atric evaluation results in a diagnosis of major depres- not consider this to be an instance of cosmetic sion for a young woman who has begun to wake up psychopharmacology. To move even closer to the at 4 am every morning feeling exhausted, despondent, middle of this dilemma in search of a legitimate, or nauseous with a visceral form of free-floating anxiety shall I say, an ontologically distinct cosmetic psy- and unable to shake off thoughts of death – her own, chopharmacology, suppose the person with dysthy- her mother’s, her pet’s, even the supposed deaths of mic features, for whom meditation is an important starving children the world over who cannot find adaptive mechanism and may be one of her few enough to eat. She is herself unable to eat and has remaining pleasures, has a melancholic tempera- lost 16 pounds in the last 3 weeks. Food tastes like ment. She has always been prone to pessimism and sawdust and its sensation in her stomach triggers dark moods. It is part of who she is. It is normal for severe anxiety about losing her tenuous hold on self- her to be darkly pessimistic and depressed. However, control and possibly committing suicide. Violent, not being able to effectively meditate constitutes an frightening images of death by gunshot wound to the existential crisis for her in that it takes away part of head intrude on her consciousness.7 Uncle!8 Enough her purpose in living, and she experiences this exis- said. No one can dispute the use of Prozac to treat tential crisis as an illness, if only in the metaphysical depression of this sort. It is the sort of case that causes sense. Shall we give her Prozac, and if we do, does this finally constitute a cosmetic use of psychophar- 7These details are taken from an actual case history.
macology? As Sperry & Prosen (1998) write, in all 8In some cultures, one cries ‘Uncle!’ when one’s arm has been likelihood practitioners would split their vote on this sufficiently twisted such that no further persuasion is needed.
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ing in and of itself does not promote growth and self- The problem of suffering
actualization, or transformation. Chronic depressed Why can we not be certain that giving Prozac to the mood and purposelessness often serve no useful pur- person whose depressed mood is interfering with her pose, especially when they might be eliminated with ability to meditate constitutes an instance of cosmetic pharmacotherapy, and most especially when our sub- psychopharmacology? In a sense, we are back to our ject experiences her chronic depressed mood and beginning: if this is an existential ailment, what is purposelessness as a form of suffering that she would wrong with treating it with Prozac? However, this gladly do without, even if there is a price to be paid.
time we ask the question while also wondering What makes sense as an abstraction from an outside, whether treating our meditator’s existential ailment universal philosophical perspective looks ridiculous with Prozac might not be an instance of cosmetic when we try to say that the suffering of this particular psychopharmacology. There are two important issues subject – this real person in real time and space who here: (1) the inevitability of divergent views on the is having trouble in meditating and feels like she is nature of suffering and its role in the human condi- losing what little joy is left in her life – is suffering tion and (2) our continuing uncertainty about the that ultimately exists for her own good; is an essential nature of psychiatric illness and the diagnostic system part of the human condition, ignoring that it is her human condition; and should not therefore be medi- Sperry & Prosen (1998) discuss the first: they con- cated away. In addition, the view that depression can tend that the reason the vote would be split is that be useful and desirable makes light of the fact that the possibility of prescribing Prozac, not just in this most forms of depression involve suffering that con- but in each of the above instances, evokes different sists of significant cognitive, affective and physical views on human nature, especially different views on dysfunction (Glannon, 2003b). Those forms of the human condition and the role of suffering in the depression therefore threaten rather than contribute human condition. They find two very distinct perspec- to meaningful life. Here, the legitimate purpose of tives on human nature: ‘In one view, life is not meant antidepressants is not to enhance cheerfulness or to be a state of continuous happiness, contentment, social desirability, but to restore people to a normal and well-being. In fact, life is largely a struggle filled level of functioning in their lives (Glannon, 2003b).
with pain, disappointment, grief, mourning, and sad- It follows that where Prozac does this, it has served a ness. In the other view, life can and should be as legitimate clinical as opposed to cosmetic purpose.
fulfilling and actualizing as possible. Pain, anxiety, There are at least two reasons why we cannot be sorrow, and sadness are symptoms that can and certain that giving Prozac to the person whose should be alleviated with whatever means possible’ depressed mood is interfering with her ability to (p. 56). On both accounts, suffering is an evil; how- meditate either does or does not constitute an ever, only on the latter account is it to be eliminated instance of cosmetic psychopharmacology. First, whenever, wherever and with whatever (moral) assuming Prozac has worked in this case, in alleviat- ing our subject’s suffering and improving her health, On the first account, suffering is a ‘privileged’ state, well-being and overall functioning, we have remedied and treatment with Prozac for non-clinical (normal) a harmful dysfunction as defined by Wakefield (1992).
and subclinical (abnormal but also undetectable) con- We have treated a disorder, in other words. We have ditions ‘robs life of its edifying potential for tragedy’ treated what is on our subject’s account, and perhaps (Sperry & Rosen, 1998; p. 56). The experience of also on our own account, an illness of sorts – again, sadness, after all, is morally and developmentally nec- if only in the metaphysical sense. The relief of suffer- essary for human growth and self-actualization. This ing by all appropriate, clinically sound means is a is part of what is lost when Prozac is used for cosmetic legitimate medical, or more broadly, clinical purpose purposes to treat existential ailments that are part of – as some of those who prescribe medications are not the human condition. On the second account, suffer- medical doctors but clinicians of another sort. Sec- Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
ond, we cannot be sure that this is an illness only in disorders and thus creates a shared discourse despite the metaphysical sense. Perhaps, it is also physiolog- competing and incompatible theoretical and aetiolog- ical. We can no longer assume that certain traits or ical claims about the nature of mental disorder. With states, such as irritability, pessimism, a certain dark- a descriptive taxonomy like the DSM, illness catego- ness of mood or nervous tension, reflect one’s basic ries like major depression, dysthymia and melancho- temperament and are merely part of the human con- lia are identified and arranged into sets of observable dition (Sperry & Prosen, 1998). In fact, if tempera- psychological, physiological and behavioural sign and ment is part of the human condition, it is part of the symptom clusters, or syndromes (Radden, 2003).
biological human condition, for temperament is now However, descriptivism comes in two guises: (1) onto- known to be biologically based, at least partially her- logical descriptivism, which is the view that categories itable and present from birth (Watson, 2000). Perhaps such as depression refer only to those observable there is something biochemically, physiologically or signs and symptoms and not to any underlying causal genetically awry in our meditator’s processes of framework and (2) causal descriptivism, which chemical neurotransmission.9 Who can say that one’s implies identifiable, underlying causes that give rise irritability, pessimism, darkness of mood and the ner- to the observable signs and symptoms. On the second vous tension that prevents one from effectively med- analysis, depression refers not only to the observable itating is only metaphysical illness and not, or not features of a depressive state but also to its underly- also, physical disease – in which case it is harder to label the case an instance of cosmetic psychopharma- Once again, consider our dysthymic patient with cology? This lands us squarely on top of the second the melancholic temperament who is having difficulty important issue identified in our search for an onto- in meditating, and who resides in the middle of that logically distinct cosmetic psychopharmacology, region where an ontologically distinct cosmetic psy- namely, our continuing uncertainty about the nature chopharmacology is most likely to be found. Whether of psychiatric illness and the diagnostic system that dysthymia and melancholy can be equated for pur- poses of treatment with clinical depression, for which we have already determined Prozac is a legitimate medical treatment and does not constitute an Descriptivism, causal classification
instance of cosmetic psychopharmacology, depends and drug cartography
on whether we adhere to a descriptivist or causal According to Radden (2003), descriptivism denotes ontology. To adopt descriptivism is to allow the simi- the epistemological approach to classifying mental larities and differences between the respective disorders adopted by the American Psychiatric Asso- descriptions of melancholy, dysthymia and major ciation(2000) in its DSM. As the term suggests, it depression to determine whether we are dealing with describes the clinical features of various psychiatric distinct conditions. To employ a causal ontology is to set aside the descriptive differences and insist that melancholy, dysthymia and depression are variants of 9The ‘biochemical deficiency’, e.g. serotonin deficiency, and ‘bio- the same underlying condition despite differences in chemical imbalance’ concepts so often used to explain the bio- appearance (Radden, 2003). Whether we call giving logical basis of depressive and other psychiatric disorders is no Prozac to our melancholic meditator an instance of longer considered adequate to describe either that which is cosmetic psychopharmacology or not depends not ‘awry’ in the biologically-based psychiatric disorders, e.g. major only on our view of human nature (Sperry & Prosen, depression, bipolar disorder, schizophrenia, schizoaffective dis- 1998) but also on whether our ontological framework order, obsessive-compulsive disorder and panic disorder – the is descriptive or causal (Radden, 2003). Given that list is growing – or that which psychopharmacologic agents our current descriptivist methododology for psychiat- ‘treat’ or ‘correct’. (Stahl, 2000).
ric nosology does not in fact establish causes, it is Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
insufficient for determining what depression is. We some evidence to think it does, at least Kramer10 and can talk about what depression does, but not about Elliott11 think so – then we might suppose all those what it is (Hansen, 2003). As we are still unable conditions constitute variants of the same biologic to carefully determine the boundaries and shape depressive spectrum ‘disorder’. Drug cartography of depression, I am skeptical we can actually appears to show in sharper relief than the science of locate the boundaries and shape of a cosmetic biological psychiatry currently warrants what causal classification holds implicit. Nevertheless, if science Radden (2003) discusses another interesting dis- someday shows that all these conditions do in fact tinction. She points out two widespread trends in cur- consist in the same depressive spectrum disorder, rent psychiatric classification: the first is the tendency then there can be no sharp ontological distinctions, at to attribute various forms of masked depression to least in the middle of our prescriptive practice those whose symptom picture is contrary to that por- dilemma, between that which is said to be cosmetic trayed in traditional (Western) classifications, for psychopharmacology and that which is not.
example, Chinese women who do not feel depressed but whose somatic symptoms are nevertheless taken Conclusion: ‘a thousand cartwheels’
to indicate an underlying, masked depression, or men in Western society whose acting out, substance abuse In truth, I resonate with Elliott’s (1999a, 1999b, 2000, and antisocial behaviour similarly are taken as 2003, 2004) exquisitely articulated concerns about the expressive of an underlying, masked depressive dis- medicalization of human unhappiness and the moral order. Stimulated by rapid psychotropic drug devel- implications of enhancement technologies. However, opment, the second trend, called drug cartography, I find cosmetic psychopharmacology – the term, the constitutes ‘a remapping of psychiatric categories concept and, to the degree it exists, the practice – based not on traditional symptom clusters but on psy- suspect for all the reasons articulated above, not the chopharmacological effects’ (p. 38).
least of which is that the ‘conundrum’ of cosmetic For example, Brendel (2003b) points to the work psychopharmacology is ‘necessarily played out at a of Hudson & Pope (1990) who, based on the response historical moment, ours, when the categorization of to certain antidepressant medications of eight medi- alienation [and other depressive states] remains cal/psychiatric conditions including major depression, ambiguous’ (Kramer, 2000; p. 14). To some degree, bulimia, panic disorder, obsessive-compulsive disor- when we treat depression we simply do not know der, attention deficit-hyperactivity disorder, cata- what we are treating and therefore cannot say that plexy, migraine and irritable bowel syndrome, this treatment is merely or exclusively cosmetic.
argue that all these disorders may share a common Andrew Solomon (2001) sums it up very well: ‘The pathophysiologic abnormality and thus could be shape and detail of depression have gone through a understood as a single affective spectrum disorder.
Similarly, a variety of problems with impulse-control 10Listening to Prozac presents numerous instances of supposed including overeating, gambling, paraphilias and vari- personality change in response to treatment with Prozac.
ous patterns of alcohol and drug abuse are increas- 11In Pursued by Happiness and Beaten Senseless: Prozac and the ingly regarded as obsessive-compulsive spectrum American Dream, Elliott (2000) writes: ‘How many patients disorders because Prozac effectively treats them [take Prozac for alienation], and whether Prozac actually cures (Radden, 2003). Thus, if Prozac, which acts at the them, remains to be seen. It may be small in comparison to, say, level of gene expression in chemical neurotransmis- the number who use Prozac for depression. But I take it from sion (Stahl, 2000), effectively treats – apart from my psychiatric colleagues, from the case histories in Kramer’s whether it should be used to treat – not only major book and others, and from my many friends and acquaintances depression but also dysthymia, melancholic personal- who have used the drug, that whether it affects alienation is at ity and existential alienation – and there is at least Blackwell Publishing Ltd 2005 Nursing Philosophy, 6, pp. 131–143
thousand cartwheels, and the treatment of depression ous associations of intellectual brilliance and later, has alternated between the ridiculous and the even genius – associations that are absent from sublime . . . To understand the history of depression today’s conception of depression, where one crite- is to understand the invention of the human being as rion is poverty of thought: ‘Melancholia was the dis- we know and are him [or her]. Our Prozac-popping, order of the man (of genius, of sensitivity, intellect, cognitively focused, semialienated postmodernity is and creativity), whereas today’s depression is both only a stage in the ongoing understanding and control apparently linked with women in epidemiological fact and associated with the feminine in cultural In voicing my suspicions about cosmetic psychop- ideas. Depression’s gender link is the reverse of the harmacology, I have asked far more questions than I masculine and male associations of melancholia’ (p.
have attempted to answer. Yet, I must ask one more.
40). Is this perhaps why Kramer (2000), who started To begin with, for whom is cosmesis most at issue? it all, believes that ‘much of the discussion of cos- Who, by and large, uses cosmetics? Who, for the metic psychopharmacology is not about pharmacol- most part, opts for cosmetic surgery? In Listening to ogy at all – that is to say, not about the technology.
Prozac, whose personalities and selves are being Rather, “cosmetic pharmacology” is a stand-in for transformed?12 For whom, then, does Kramer coin worries about threats to melancholy’ (p. 16). I tend the term ‘cosmetic psychopharmacology’? Who, in to agree that ‘much of the discussion of cosmetic psy- fact, reports depression in the greatest numbers?13 chopharmacology is not about pharmacology at all’, Overwhelmingly, the answers to all these questions but I do not think the issue is only ‘threats to melan- are: women. To the degree it really exists, is cosmetic choly’. There are other threats at large, and I cannot psychopharmacology, then, a gendered concept, or help but wonder what part is played in this debate by gendered practice? Of course, it is beyond the scope the fact that most of the people requesting or being of this paper to address the question, but I will note given Prozac for whatever purposes, cosmetic or clin- this: Radden (2000, 2003) has examined the relation- ship between today’s depression and the melancholia of old. For hundreds of years, she writes, influenced by Aristotle and almost every subsequent thinker References
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