Through the Times With Peter Kramer, M.D.

When he first entered psychoanalysis as a patient, this 22-year-old Marshall scholar envisaged his future as that of a melancholic, isolated writer. Instead, he uncovered a repressed desire to become a psychiatrist. Through the years, Peter Kramer, M.D., has interwoven the two careers of writer and clinical psychiatrist and followed a life path that he has described as "up from melancholy."

In 1970, Kramer had graduated from Harvard College with high honors in history and literature and was attending University College in London on a postgraduate scholarship, yet he was uneasy. "I was someone who was very interested in literature and philosophy," Kramer told Psychiatric Times. But that was during the Vietnam War years, and many young Americans felt the imperative toward relevance, service and practical good.

Partly because of his need to feel relevant and partly because of his lack of pleasure in his own academic successes, he entered psychoanalysis at Hampstead Clinic, the Freudian epicenter in Great Britain. "In the course of being an analytic patient, I came to the realization that I had in some ways always wanted to be a doctor but had set that goal aside. In particular, I wanted to be a psychoanalyst," Kramer added. In Kramer's newest book, Against Depression (New York: Viking, 2005), he writes of those life-transforming years:

When I announced that I wanted to enter medical school and become a psychiatrist, my analyst did not discourage me ... My analyst wanted me to understand that the wish, from childhood, to protect my relatives--the need to ward off depression and to conquer disease--was shaping my career choice ... I do not deny that my attitudes toward mood disorder have deep roots.

Born in New York City just after World War II, Kramer grew up in the shadow of the Holocaust. He wrote in Against Depression:

All my relatives were German Jews. Those few who had managed to get out--they included my parents, my grandparents and one great-grandmother--had done so at the last possible moment. Most other family members were killed or died of medical neglect.

Disease also marked the family. In the first four years of Kramer's life, his father, a pharmacist, was hospitalized twice with tuberculosis.

While in London and in the summers back in the United States, Kramer enrolled in the science courses that prepared him for medical school. In 1972, he entered Harvard Medical School and quickly began exploring the multiplicity of theories and models found within psychiatry.

"I started seeing psychiatric patients in my spare time, such as it was, from the first month I was in medical school at Harvard. I saw patients at Beth Israel Hospital, working mostly with Ted [Theodore] Nadelson, M.D.," he said. "By the time I had finished my undergraduate training, I had almost the equivalent of a residency in the model that Harvard used at that time, which was very Freudian." On a more informal basis, Kramer studied community psychiatry with Milton Mazer, M.D.; psychiatric theory with Leston Havens, M.D.; and social psychiatry with Robert Coles, M.D.

After Harvard, Kramer interned at the University of Wisconsin Hospital in Madison. Although he had a medical internship, he informally began studying group and family psychotherapy with James Gustafson, M.D., and Carl Whitaker, M.D.

When it came time for Kramer to do his psychiatric residency, Havens suggested that he experience an alternative to Harvard's psychoanalytic model by going to Yale University, which emphasized biological psychiatry and community mental health.

"Leston Havens was right to expose me to nonpsychoanalytic psychiatry. I think he saw a pragmatic streak in me. Although I considered myself to be intellectual, I was prone to a brusque practicality," Kramer said.

Havens encouraged taking a broad view of psychiatry. "Yale sent me in that direction," Kramer added, "as did my work in the government, where as a young man, I had oversight of a very broad research portfolio."

From 1980 to 1982, he worked as acting director of the Division of Science for the Alcohol, Drug Abuse, and Mental Health Administration and then as special assistant for science to the agency's administrator. Kramer often served as a liaison between the scientific community and members of Congress. During those same years, he became an instructor and then assistant clinical professor in the department of psychiatry at George Washington University in Washington, D.C. He also rose from assistant professor in 1982 to clinical professor in the department of psychiatry and human behavior at Brown University.

Psychiatric Times

Just after his residency, Kramer wrote a novel. Although the novel was never published, Kramer said it did help him become a columnist for PT.

"I was talking about it with Walter Reich, M.D., during one of the American Psychiatric [Association] meetings in Dallas, and John Schwartz [M.D.] came up to him and asked if he would want to review a book. Walter said 'No, but Peter should, since he had just written a novel.' So John asked me to send him the novel, and he'd look at it. He also asked me to review a book by Samuel Shem [pseudonym for Stephen Bergman, M.D.], and I did."

The book review appeared in PT in August of 1985. Schwartz then asked Kramer to review another book, but he had other ideas. He blurted out, "No, I am not going to write a book review; I'm going to write a column for you." The first "Practicing" column, titled "Limits of Power," appeared on the front page of PT in October of 1985. It discussed a patient Kramer knew of who believed that psychotherapy was going to save his life in the face of cancer, but who subsequently died. "I questioned how magical we want psychotherapy to be," Kramer said.

In an act of chutzpah, Kramer then called Schwartz and said that the column should not be on page 1, but rather on page 2 or 3 every month. Schwartz responded that he had a pharmacology column on page 3. Kramer was undeterred: "I said something that I have never again said in my life, and I don't know where the confidence came from. 'Anybody can have a pharmacology column,' I said. 'Nobody has what I am going to write for you.' I took over page 3 and was there every month for 10 years."

Kramer served as a senior editor and contributing editor for PT through 1997. His work in community psychiatry, hospital psychiatry, liaison psychiatry and research oversight helped prepare him to write the column.

"I wrote the column from the point of view of someone practicing psychiatry every day, but also someone who was aware of a range of experiences in psychiatry," Kramer said.

"Psychiatrists really read that column," he added. "John did a [readership] study once ... and at that moment, it was the most read part of the paper. People would actually come up to me at psychiatric meetings and look at me as if they had seen me somewhere and ask where they had seen me; I would say, probably on your bathroom floor."

The column led directly to Kramer's first published book, Moments of Engagement: Intimate Psychotherapy in a Technological Age (New York: Norton, 1989; Penguin paperback, 1994), which presented case histories and revelatory encounters with patients and discussed the tools--from medicine to empathy--used to help patients change.

Kramer explained that a book editor at Norton who read his "Practicing" column in its first year invited him to write a nonfiction book for her. The irony of the request was obvious to Kramer. "Here I had been walking around with a copy of my novel and not getting anyone to read it," he said, "and I got an offer from a publisher to sit down and write a book."

Indirectly, the "Practicing" column also led to the publication of Kramer's bestseller Listening to Prozac (New York: Viking, 1993; second edition, Penguin, 1997). In the active private practice he maintained through the years, Kramer observed "changes in my patients that looked to me like changes in personality." What's more, many of those patients attributed particular powers to fluoxetine (Prozac). "I wrote a couple of columns about those issues for PT, and I think in [one of] those columns coined the phrase 'cosmetic psychopharmacology,'" he said. Those columns led to his being interviewed about Prozac in Newsweek and other publications.

Kramer then developed a book proposal and got an agent for what became Listening to Prozac, a book about the "biology of personality" that also explored the ethical questions surrounding a drug that many of Kramer's patients said made them feel "better than well," like different people.

When the book came out, it evoked high praise and strident criticism. Some mental health professionals claimed it dismissed psychotherapy. In statements in Psychology Today, Kramer warned that many have misinterpreted his book, that it is "really more a philosophical book about how the self is redefined in a culture that has biological instruments for changing things that previously were changed through religion or talk therapy" and that psychotherapy remains an important treatment for anxiety disorders and helping patients live with depression (Epstein, 2001). In fact, Kramer has been a member of the editorial board of the AmericanJournal of Psychotherapy for many years.

Because of the book, Kramer was interviewed nearly every day for a year and became, according to The New York Times, possibly the best-known psychiatrist in America. Despite his celebrity status, Kramer sees psychiatry and writing as "humbling professions."

"The fact that you are well known doesn't make your patients get better faster and doesn't make the sentences more felicitous. I think you just have to work at these things every day," he said.

He admits to having "mostly the same life for 20-plus years," which involves writing in the morning and seeing patients in the afternoon. "I did it when it was hard to make a living doing that, and I do it now when it is a little easier to make a living at it," he said. "I do speak more around the country than I would have."

Fame's primary benefit for Kramer is that it has enabled him to write several books. His third published book, Should You Leave? (New York: Scribner, 1997; Penguin paperback, 1999), introduces readers to modern theories about relationships. It features relationship dilemmas of fictional patients, using them as openings to discuss various views of giving advice. The views range from Harry Stack Sullivan and Sigmund Freud to columnist Ann Landers.

Kramer's next book, Spectacular Happiness (New York: Scribner, 2001; paperback, 2002), is a novel about a thoughtful, passionate community college teacher who becomes increasingly disgruntled as he underachieves in midlife, his marriage disintegrates, his beloved son leaves and he sees society becoming increasingly driven by meaningless consumption. He expresses his dissatisfaction by deciding to blow up beachfront homes on Cape Cod.

"The themes of my last four books are some cultural construction of happiness that relates to psychiatry," Kramer told PT. Listening to Prozac is really about what we demand of people in terms of personality traits and how much happiness we have a right to expect, he said. Then, Should You Leave explores how our notions of happiness are connected to our notions of intimacy or autonomy.

The novel, Spectacular Happiness, is about how we understand happiness in a culture that also emphasizes wealth and celebrity, and Against Depression is about how a particular disease affects our vision of what the good life is and what the good life might look like if we were better at treating the disease.

Disease of Depression

Against Depression has been described as a provocative sequel to Listening to Prozac. In the prologue, Kramer observes that he has written a polemic, "an insistent argument for the proposition that depression is a disease, one we would do well to oppose wholeheartedly." He warns against equating depression with a heroic artistic stance, one we think humankind might be worse off without.

When asked about the relevance of the book for psychiatrists and their patients, Kramer told PT, "For doctors recommending the book to patients or having it in their waiting rooms, the book's middle scientific section really walks patients through the contemporary scientific understanding of depression and its treatments."

Numerous scientific studies are cited linking depressive symptoms with abnormalities in the hippocampus and prefrontal cortex of the brain. Kramer also emphasizes that depression is more than a brain disease. "It is a neurologic, hematologic and cardiovascular disease. Overactivation of stress pathways causes a liability to clots and arrhythmias--and alone or together, these predispose to heart attacks, silent strokes, disturbed mood and sudden death," he wrote.

In another section of the book, Kramer asserts that the criteria for major depression are "arbitrary in every regard." In explaining that conclusion to PT, Kramer said, "Originally, I was very opposed to the narrow categorization of DSM-III, but now admit it turned out to be a brilliant idea for research purposes. We just needed this arbitrary definition. But the research that justifies the definition also demonstrates that it is arbitrary.

"You need to diagnose depression by five or more moderate symptoms for two weeks. Yet, people with four symptoms, mild symptoms or 10 days of symptoms really sit on a spectrum with the people who meet the full definition, and those who almost make it have fairly bad outcomes. I think we just know that we haven't captured depression. The way we will capture it probably is through a biological marker or set of markers.

Some of the brain research that we have seen in the past seven or eight years has really made it clear that depression is a disease--there are neuroanatomical changes that are associated with depression, either causing it or being caused by it. But we don't have the kind of consistent marker that allows us to say in the way we can say with polio, 'You have the symptoms of the disease, but you don't have the disease,' because we don't have the biological marker.

"That's our next step with depression. We would like to be able to say, 'Yes, you have five symptoms for two weeks at a moderate level, but actually you have an imitator, whereas the person across from you has only four symptoms but we know from the biological marker that it really is depression.'"

Beyond the scientific questions and debates that Kramer explores in Against Depression, he also raises moral, ethical and philosophical issues. "The idea I'm considering is what it means to embrace the notion that depression is a disease and what kind of window that gives us on our culture. For two millennia or more, human beings have been looking at other human beings with depression or experiencing depression themselves, thinking about it and writing about it, but not being able to influence it very much. Depression relates to all kinds of theories about what the good society or bad society is," he said. "The book is really about how it would change our thinking as a culture just to begin thinking of depression as a disease, and how it would change it more if we really got better at treating or ideally preventing it."

For his next book project, Kramer is writing a brief biography of Freud. It will be part of a biography series called Eminent Lives, edited by James Atlas. The book will probably not be published until 2007, Kramer said, since he has "a lot more reading to do about Freud." Beyond writing books, Kramer has written reviews, commentaries and articles for The New York Times, The Washington Post, Slate and Salon, as well as many medical journals.

Currently, Kramer still works as a clinical psychiatrist four afternoons a week, and many patients come because they or their referring clinician have read one of his books. "Because of Listening to Prozac and Against Depression, probably most of the new referrals are people with ambulatory mood disorders. Should You Leave brings me some couples for counseling," he said.
This year, Kramer also was named host of "The Infinite Mind," a National Public Radio show focusing on mental health. Already, he has covered such issues as Asperger's syndrome, electroconvulsive therapy, and food and mood. In prior years when he was a guest host, two of his programs--"In Any Language: Mental Health Care for Immigrants" and "Domestic Violence"--won awards.

Looking toward his future, Kramer expects to put more of his energies into writing.

"I am a doctor for the long run. I really do enjoy it," he said. "But I could imagine myself retiring from medicine and just writing, whereas I could not imagine myself retiring from writing and just practicing, so I think the more loyal tie is to writing. Both feel very much like privileges."

References:

Reference1. Epstein R (2001), Is everybody happy? Peter Kramer wrote the manual to Prozac; now he's trying his hand at fiction. Psychology Today. Nov.