Congress in Washington, DC. >> Leonard Bernsteain:
Peter Kramer is our guest. He is a columnist. He is a novelist.
He is a psychiatrist on the
faculty at Brown Medical School. But as he says in his new book,
he's basically known as the "Listening to Prozac" guy. All of you who are
here, I would say, I'm willing to bet
have read this book. And his new work is
called "Ordinarily Well".
It's a follow on to the best
seller, "Listening to Prozac". And please join me in
welcoming Dr. Kramer. [ Applause ] [ Inaudible Discussion ] Can you hear us now? >> Yes.
[ Inaudible Discussion ] >> Dr. Peter D. Kramer: Better? [ Inaudible Discussion ] >> Leonard Bernstein:
Does my microphone-- Did my microphone pick
up Dr. Kramer's voice? >> No.
>> Dr. Peter D. Kramer: Well, I--
oh, even I can tell, all right. So, you know, I've been to
some of the other sessions here where the better--
yet better selling and more honored authors
were speaking.
And they all start by saying
how they were saved by reading, how the library card
really brought them out of some small community
into the world. And it certainly is true for me. I am a child of immigrants. My mother was not satisfied with
the public library in our community and would drive me across
town to another library so we could take out,
you know, good enough and well-curated enough
collection of books.
So, I'm honored to be at
a celebration of reading. This really is, I know, important
in all your lives and a cause. You know, literacy
certainly is a cause. So, let me say that before
we talk about a book.
Yes. >> Leonard Bernstein: Terrific. Thank you. After reading your book, I
guess, the question I most want to know is why this
book at this time? >> Dr.
Peter D. Kramer: Yes. >> Leonard Bernstein: Twenty three
years after your best seller. >> Dr.
Peter D. Kramer: Right. >> Leonard Bernstein: Right at
time when one of eight people in America is using antidepressants. >> Peter Kramer: Right.
>> Leonard Bernstein: Why a defense
of Prozac and antidepressants? >> Peter Kramer: Most of my books
come the way writers books do out of some, you know, inspiring
thoughts, something that just needs to be written that is
writerly, some observation that needs exploring and amplifying. This really is a cause book. This is a book I felt had
to be written for the sake of the patients, which is not a
comfortable starting point for me, and maybe why it took me a little
longer than some of my other books. But I tell stories at the
beginning of the book about people who really need antidepressants,
who either have not been prescribed to them because their doctors
have doubts that have been aroused by what I think is
spurious research that claim that these antidepressants and in a
minimal say a little what depression or antidepressants are.
But spurious research had said that
these medicines are a little more than placebos with side effects. Or, who are doing well on
antidepressants in ways that are important and
are cast into doubt, "Should I continue
taking the medicine? Is it really a placebo?" And I'm not, by the way, saying
that everyone who is depressed needs to be on antidepressant or
everyone who is doing well on antidepressants
needs to stay on it. Just that that first question, do they work at all,
really can be discarded. And I think both researchers and
the press and the media had thrown that into doubt in a way that
is dangerous to patients.
>> Leonard Bernstein: But
as a psychiatrist, it's-- >> Dr. Peter D. Kramer: Yes. >> Leonard Bernsteain: -- it's
quite obvious, antidepressants work.
>> Peter Kramer: Right. >> Leonard Bernsteain:
Has there-- How has the-- How are those doubts been raised? >> Peter Kramer: So, of course,
doctors see these medicines work. And the doubt that has been raised
isn't whether people get better on antidepressants, but
whether they get better based on the inherent efficacy
of the medicine. That is you could get better
just because of your faith from the doctor and your faith
in pills or you could better because these medicines really work.
That is the chemicals, they
are taken into your brain and they do something that's useful
for people with mood disorders. So, I want to just say, because
I have talked a lot to the public and I know that not everyone
knows this, what depression is? When we say depression,
what we're talking about? So, depression isn't
just ordinary sadness. It's a syndrome. It's a constellation of symptoms.
It's a disorder that's been
recognized, you know, since the time of your properties, starting
under the name, melancholia. And we-- And you know
it when you see it. Lately, it's been defined
by symptoms, right? So, people are sad. They can't experience pleasure.
They're slowed down. They're apathetic. They may be suicidal. They may have problems with sleep
and appetite, low self-esteem.
But it is those things
in a way that coheres and makes it hard to
function in life. And, you know, at the
extreme, you know, you can think about Picasso
paintings or Durer etchings where people are wringing their
hands and looking at the ground, and they're emaciated and almost
starving themselves to death, and obsessed with negative thoughts. But there's a range of depressions. And some, which are, you know,
look or less recognizable in that way are still
very destructive in life.
And I think when you're in the
presence of a depressed patient, you know pretty much what that
is, it's not ordinary sadness. And the antidepressants
are medicines that human kind has had access
to only for the last 60 years. Since Hippocrates,
doctors have wanted to have chemical approaches
to depression. The first antidepressants were
developed in the late 1950s.
The concept that a
medicine would that we had to hand did this was really
elaborated in the 1950s. And then the way 1980s in Europe
and here, we have this newer group of antidepressants beginning with
Prozac and names that are familiar to you or things like Zoloft
and Celexa, Effexor or Lexapro. That's the class of
medicines we're talking about. >> Leonard Bernstein: Is it true that we still don't
really know how they work? >> Dr.
Peter Kramer: It is true. >> Leonard Bernstein:
How can that be? >> Dr. Peter Kramer: Well,
the brain is very complicated. In "Listening to Prozac," I
quote a scientist who says, "If the brain were simplest-- simple
enough for us to understand it, we would not be complex enough
to have that understanding." The-- We know a lot
of antidepressants.
We know at the first level that
these medicines affect patterns of transmission in the brain, the way cells signal one
another with chemicals. And we know that these medicines
restore resilience in the brain in some quite general way. So, they make it possible for people
to make new cells in the brain. Something we've only known
for about 20-25 years is that the adult human brain
continues to make new neurons in certain parts, and
they allow the brain to make new connections
between cells.
And those things are
really muted in depression. Depression is a multisystem
illness that affects the brain, the brain's capacity to learn,
but it also affects bone, blood elements, hormonal glands. So, this is a body-wide disorder. But you know, at the core, we
have problems with the resilience in the brain and the
medicines restore that.
I start the book with an
anecdote about a friend of mine who said we had a serious stroke,
and it turns out that this kind of stroke, there's more
recovery from this kind of stroke if you're given antidepressants
early. Not because they fight depression but because they restore the
brain's ability apparently to elaborate the connections
between cells in this way. And this friend of
mine, his patient, was not getting antidepressants
because of this sort of created prejudice against them. And that really was the sort
of the trigger for my thinking about writing a book like this.
>> Leonard Bernstein: So, we
don't know exactly how they work? >>Dr. Peter Kramer: Right. >> Leonard Bernstein:
But you as a psychiatrist and somewhat rare among
psychiatrists, you do both talk therapy
and prescribing-- >> Dr. Peter Kramer: Right.
>> Leonard Bernstein:
-- of antidepressants. So-- And you obviously see
that all of these works. >> Dr. Peter Kramer: Yes.
>> Leonard Bernstein:
So, where on that scale between all medicine
and all talk therapy-- >> Dr. Peter Kramer: Right. >> Leonard Bernstein: --
do you lie and how do-- does the patient pick his
or her place on that-- >> Dr. Peter Kramer: Right.
So, it turns out that depression is
a relapsing and remitting disorder. It is chronic. People who've had a few
episodes are likely to have more. And that the later
episodes tend to be graver, they have more serious
symptoms, they last longer, they have more trouble responding
to whatever intervention we make.
So, we like to interrupt depression. And to me, the measure of worth
of a treatment in depression is that it works, so that the cases
made for exercise and meditation and yoga and a religious
counseling and so on. And the question is,
are you getting better? And if you're not getting better, the best tested remedies are
psychotherapy and medication. And my-- I usually
start talking to people.
I want to know what's going on. And that in itself seems to
have some mitigating effect. And my measure as a doctor, and I think the doctor really is
the instrument here, is worry. If I start worrying that
this is really solid, that I'm not budging it, that
things are getting worse, we're falling behind,
I do tend to turn to medication, and it tends to work.
You know, there are-- You know, I don't know how well you
think these medicines work, there's a figure going around
that appears in the press lately. And part of this book is
quite critically depressed in how they look at research. But the figure is 30%, that
antidepressants help 30% of people. With that number which is wrong
in three ways comes from a study, very terrific study,
sponsored by the NIMH, the Institute of Mental
Health that looked at people who had been depressed, on average,
for 15 years, were in the seventh or eight episode of depression.
That episode had lasted two years. Most of the patients in
addition were alcoholic or had a second mental illness. And in those patients, the
first antidepressant tried at ordinary doses caused
a remission. That is the episode of
depression ended in 30%.
To me, that's actually
astonishingly good figure, you know, why hadn't those patients
gotten better already. Half of them lost half
their symptoms. If you look in an unselected
population, primary care doctors, patients coming in, you see
much higher levels of response. So, we're not really discussing,
do people get better on this.
There was a Swedish study looking at primary care populations,
nonsuicidal people. And by six months, 90% of them had
lost half their first symptoms. So, you know, people are very
responsive to these medicines. And the controversy that the
book is about is this question about whether depression is also
very responsive to placebo pills.
I think it's not but it's
kind of a complicated story. And I try to tell it complexly
through stories from my practice, stories about the history
of psychiatry, and also some introduction to sort
of basic statistical approaches to research, how do
we measure depression, how do we measure change,
how do we combine studies, what makes this thing sort of-- a medicine is working and how do
doctors outside psychiatry treating things like diabetes and asthma and
so on think about their treatments, you know, how do we compare. >> Leonard Bernstein: So,
at the risk of asking you to boil down your entire book-- >> Dr. Peter Kramer: Right.
>> Leonard Bernstein: -- why doesn't
the placebo hypothesis worked up? >> Dr. Peter Kramer: Well, placebo
is very complicated, you know, you go into a study and all
sorts of things happen, right? You get a lot of attention from
doctors, time passes, you know, you return to employment
whatever it is. So, you need to say, what would
happen if we hadn't given the pill. So, some people are on the pill,
some people are not on the pill.
Everybody gets a little bit
better, the people on the pill tend to get a lot better, and the pattern of recovery is really
different on placebo. Often, a few symptoms get better
in a lot of people on medication. Some really don't get better at all. They don't even enjoy that
little placebo effect, they have side effects, they're
troubled by being on the medicine and many of them get a lot better.
And so, the question first of
all is what's going on in the "placebo arm or the trial?" Are people responding to
their beliefs about the pill or is it all the support? And then the second
question is what is the-- you know, what does
the medicine add. And it turns out the
medicine adds a lot. And I call the book "Ordinarily
Well" because the level of what's added is at the level
of what's added by, you know, most treatments that doctors give
for most common chronic ailments, ailments like depression. >> Leonard Bernstein:
I was going to ask you in fact the very next question.
In the first book, you coined
the phrase "better than well." >> Dr. Peter Kramer: Right. >> Leonard Bernstein: And I
assume "ordinarily well"-- >> Dr. Peter Kramer: Right.
>> Leonard Bernstein:
-- came from there. >> Dr. Peter Kramer: Yes. >> Leonard Bernstein: Could
you tell us about that? >> Dr.
Peter Kramer: Right. So, "Listening to Prozac" is really
about the biology of personality. And it turned out when these new
antidepressants became available, they didn't just get people
better from depression. I had patients coming
in who'd say, you know, I'm pass that episode of depression.
But in addition, I'm less socially
anxious, I'm more comfortable, I seem to be better at my
job, better at parenting. And I call that phenomena or one of
my patients really called it better than well, he said it
was better than baseline. And I asked the other doctors and
I was writing columns for doctors at that time and, you
know, are you seeing this? And then I wrote about
why the biology of these medicines might
lead to that sort of result. And it was a worrying book that is if we could reliably
influence personalities in ways of the Culture Awards might
doctors overstep in certain ways.
And one reason I thought I in
particular ought to write this book, that book was about
tweaking personality with medication, it was worrying. It was to say, those
worries don't really extend to the core uses of medication. Depression is a really destructive
ailment, it's very common, we have tools to treat it if they're
quote for we are to be using them. >> Leonard Bernstein: We haven't
talked about side effects-- >> Dr.
Peter Kramer: Right. >> Leonard Bernstein: --
which are a huge issue-- >> Dr. Peter Kramer: Yes. >> Leonard Bernstein:
-- in antidepressants.
>> Dr. Peter Kramer: Right. >> Leonard Bernstein: One
of the things I didn't know when I read the book is
that when Prozac came out, you point out that it was adored
not so much for its efficacy but for the fact that it had
so many fewer side effects. >> Dr.
Peter Kramer: Right. >> Leonard Bernstein: Can you
tell us about antidepressants and side effects and how much better
are we doing these days in terms of allowing people to
be on these medications without these side effects. >> Dr. Peter Kramer: Right.
So, the early medicines that I write
about, one called imipramine worked. They treated depression, but
they were dangerous in overdose, you could commit suicide
on them easily. And they made people feel
drugged, they give you a dry mouth, they affected the ability
of your eyes to accommodate, moving between near and far
vision, they give constipation, urinary problems in
men particularly, people really felt
they were on a drug. And I think when medicines like
Celexa and Prozac came out, even doctors didn't
understand how important it was that they had a different
side effect profile.
Now, these medicines have
lots of side effects. But they-- People on them sometimes
don't feel especially they're on a drug. And if you're going to be
on a medicine for, say, six or nine months taking it
everyday, it's very important that you just feel well, not that
you just feel less depressed, but then you can go back to your
business not being always aware if you're on a medication. These medicines have side effects.
One that is very much of
concern to us and is written about a lot is the possibility that
people would get more suicidal, and even that people
who are depressed but have not been suicidal
will, for the first time, feel suicidal on medication. It turns out this was an
overlooked side effect of the earlier antidepressants. Once this became clear
that this was a possibility on the new antidepressants, it was
found in the older antidepressants, it was found in a lot of the
drugs given for epilepsy, it turns out to be true that a
number of classes of medication that affect transmission
of the brain have that risk because we're complexly wired. And the medicine-- You know,
it's people who were set up to have these transmitters
do one thing in their brain, and not everyone has
that same pattern.
So, we're-- we watch
people very closely when they first go
on these medicines. They can cause people to
have less sexual interest, the newer antidepressants, be slower
to have orgasms, very troubling, less common in young people, very troubling especially
to young people. And then, lots of the ordinary
side effects that you see with many medicines like
nausea, headache and so on, well not especially
common are, you know, possible side effects
to these medications. So, they're not without a price.
And using for a long time, there
are late-appearing side effects, people can actually get more
apathetic and it's sort of an art for doctors to distinguish
between apathy as a side effect which often can be
handled or reversed and a return of the depression. So, these are medicines
that are best used expertly. >> Leonard Bernstein: And yet,
it appears and it's quite common for people to be on antidepressants
for many, many years. >> Dr.
Peter Kramer: Yes. >> Leonard Bernstein: And it's OK? >> Dr. Peter Kramer: Right. Well, we don't know.
I mean, we've been sort of lucky. There were lots of worries
about certain biochemical events that might happen that make these-- would make these medicines
dangerous in long-term use. That doesn't seem to have emerged. But, we don't know.
I mean, this is a sort
of very large experiment. These medicines were developed for
people beyond six or nine months. If people had two or three
episodes of depression, especially if they've been suicidal,
their doctors tend to keep them on these medicines for a long time. We don't know enough about
what that does but we do know that these medicines
work for a long time.
There are experiments where you
have people on these medicines and you then, after a while,
put some people secretly with their permission and, you know, awareness of the overall
experiment on placebo. And it doesn't matter how far out you measure this,
weeks, months, years. People on placebo are two,
three, four times as likely to become depressed again as
people who stay on the medicine. I do take people off
antidepressants all the time.
And I take them off earlier probably than the signs I think
literature says. I'd like to watch them closely. I have the luxury in a sort of
carriage trade private practice of having people come to me often,
often enough that I can watch. An institute what's called Rescue
that if people starts sleeping, we reinstitute antidepressants fast.
But the truth is that depression
also is harmful, and that being on the antidepressants does
seem to prevent the progression of depression as a chronic disease. >> Leonard Bernstein: You raised
this in the book, but let's say, I came to you and I
said, Dr. Kramer, the antidepressants you gave me
are making me feel so much better. How much further can you take me
towards feeling really, really good? >> Dr.
Peter Kramer:
Right, right, right. So, I think our goal is ending
an episode of depression. It really is not revving people up or making them more
fluent in certain ways. But I mean, that is a tough topic,
you know, people who say, really, I'm just functioning better
as a parent, I want to stay on this medicine or I
want to go back on it, how do we deal with that.
And in "Listening to Prozac," I write about what I call
diagnostic bracket creep that once we have a tool of
the hand to treat something, do we tend to expand our definitions
of illness, just tell ourselves as doctors that we're
treating illnesses. Let me say something because we've
been talking in theoretical terms, this book and the use of
antidepressants and psychiatry in general is about people. You know, these are ailments
that really blight lives. And I try to make this book
usefully complex that is doing a lot of storytelling as well as talking
about data and the kinds of results that we're discussing here.
But what drives it, I always try
to have a certain perspective as an author to make a
book coherent is the moment where a patient is
sitting with a doctor and a decision has to be made. What do we want to
inform that decision? We want awareness of data, we want
our doctors to be experienced, we want doctors to
know about our lives, you know, not just about symptoms. And I think that moment is really
what I'm trying to think about aloud over the, you know, course of many
pages with footnotes and so on. >> Leonard Bernstein: The
patient interludes are terrific, is there a person who really
stands out in your mind who you would like to tell us about? >> Dr.
Peter Kramer: I
want to mention a person that I did not see although I
had the privilege of speaking with him who's Ray
Osheroff, his real name. And when I write this book, I
talk about starting in psychiatry, and I've been practicing
a long time. I started seeing patients, as a
medical student, in the 1970s. And in those days, on the
medical and surgical wards, I'm not talking even
about psychiatric wards which were more populated in
those days, you would see people with a kind of terrible
depression I mentioned earlier where people were barely moving and were muttering terrible
thoughts and had no hope at all.
And I think we see less of that. And when I say that, when I say that
antidepressants had been available for 20 years and weren't being used for those patients,
people don't believe it. And I talk about this
case of Ray Osheroff, he was a kidney doctor living
around here, he had a practice, he owned clinics, I guess dialysis
clinics, he became depressed, he was put on antidepressants, given
psychotherapy, did a little better, really didn't believe in the meds,
came off them, did much worse and was hospitalized here at
the nearby Chestnut Lodge. And the model there was
psychoanalysis and he deteriorated.
And despite the pleas of
his friends and family, he was not put back on medication. He became so agitated that he needed
medical attention to his feet. And I spoke to him later in
life and he sent me transcripts of team meetings, kind of the
meetings where doctors and nurses and so on plan defeating
their patients. And they said, oh, his wish to go
back to work has to do with the fact that his rewards at work are like
a giant breast and he's, you know, looking for the kind of warmth
he never got from his father.
And finally after months
of deterioration, he was kind of rescued by a
friend and taken to Silver Hill in Connecticut and given medication. He was better in a few weeks. He was back to medical practice in
a few months and practiced medicines for the rest of his life, but he'd
lost-- his primary medical practice, lost a lot of money, his marriage
ended and he sued Chestnut Lodge. And that's why we know about this because they were experts
on both sides.
We interviewed him
and reported that. And the result of the
case is complicated, I go through it in the book. But effectively, he won
and in a settlement. And that caused a lot
of trouble in psychiatry because it caused hospital
administrators to say, look, you can't just treat these
patients with psychotherapy.
You have to give medication. Therapists were insulted
that their way of seeing things was
being shortcut and so on. And so, this turned out
to be an important case. But when I spoke to Ray
Osheroff late in life and he'd never had an episode
of depression again like this and had been on medication
all his life.
He said the literature of torture
is most relevant, you know. That this was not really--
that depression, he said, is wimp of a word, you don't
understand what it was he was going through. But it really is the case that
these medicines were not used, on a principle basis, were
not used until after that. And in a way, well, after that,
they weren't used regularly even for very severe depression.
So, it is that kind of story that
motivates the book that worries over that sort of dismissal
of these medicines. >> Leonard Bernstein: I bet people
are ready to ask you some questions. Is there anybody who
would like to ask? >> Dr. Kramer, I have
a question about people who don't respond very well
to-- at-- to the initial-- >> Dr.
Peter Kramer: Right. >> -- Medication that's
prescribed and maybe to try two or three different ones and maybe
other certain group of people who don't seem to respond
to any of them. I was just wondering, is
there something that you see that these non-responders have
in common or someway to kind of understand how to perceive with
people that have that presentation? >> Dr. Peter Kramer: Right.
So, the question is
about non-responders. And, you know, sadly, there are
people who don't respond at all. And we have enormous need for-- to
anything that is the psychotherapy, medicines, combinations
of medication. There're few but they're-- but
because the disorder is so common, there're many of them if you
want on a percentage basis.
And, you know, sadly, for all sorts
of reasons, big pharma has retreated from development of drugs
in mental health altogether. And in the book, I write about
lots of promising avenues. I mentioned really lots of
promising avenues for research. But it's sort of mom-and-pop
garage band, sort of a research where small companies
try to get this attention to these potential remedies.
And, of course, lots of
them fall by the wayside. But there isn't really the--
aren't really the resources devoted to this problem that
there should be. That said, I do also write
about some interesting studies that I think the press
has undercovered. And one of them was done by a
consortium of universities, Rush, University of Pennsylvania,
Vanderbilt.
And what they did was really
interesting, they took patients and they allowed the patients
in the study I mentioned, fairly chronic patients well
along in the course of depression, and they said to pharmacologists,
do your worst, you know, this is not normally what's
studied, this was a pragmatic study, you couldn't have placebos
on the other side, there was nothing comparable. They just said, raise the dose
of the medicine, if you want, change it, add a second
medicine, add a third medicine. And half of the patients also were
given very intensive psychotherapy. And although the press
report of the opposite, the truce was that you didn't see a
lot of effect from the psychotherapy because the medicine did so well.
It turns out that if you
let doctors, skilled doctors and they were these kind of senior
advisors for the junior doctors in the study really try to
treat depression assertively, you get most people to respond and
you get most of them to stay well for the length of time that they
looked which was six months. But it took some people
18 months to get better. So, this wasn't, you know,
kind of an easy process. And, of course, it is also
possible since they were-- it wasn't comparison
group that in 18 months, a lot of people get
better on their own.
But this wasn't a very
chronic group that hadn't-- on the whole, the patients hadn't
gotten better on their own. So, I think one lesson from that
and as I say, it's upsetting to me that I think the press really is
happier to cover debunking stories that there have been, you know,
errors in assessing these medicines so they don't really work. But the studies in which they
are showing to work tend not to get the covers that they should. And it turns out most
people, if they-- almost everyone is stuck with
the program, and of course, disappointed, people drop out.
But almost everyone who sticks with
the program really does do better and manage to stay outside
of depression for a while. And even those people who didn't
do well on the whole didn't return to their baseline of depression, it's just that they started
accumulating some symptoms again. So, I think things are more
hopeful maybe than we imagine. >> Leonard Bernstein: Do
we have someone over here? >> Yes.
Couldn't you preface
through your comments with the fact that doctors usually sit down
with the patient for an hour and get the history before
any medication is prescribed? >> Dr. Peter Kramer: Oh yes. You know, should people be
well evaluated before medicines are prescribed? And, you know, my own
practice isn't just an hour. I may be with people
for an hour a week after week before we
decide to give a medicine.
We may know each other pretty well. But, you know, lots of
things cause depression. Early in this book, I read
about someone who has a disorder of the hormonal gland,
thyroid disorder. And the question is whether
that's causing the depression.
So, you need, you know, a good
evaluation that involves maybe in addition to-- interviewed--
in the course of the interview, you may decide you ought
to be giving blood tests and taking blood tests,
evaluating people. People really-- You know, this,
when we take the perspective that this is a medical disorder which of course isn't the only
perspective on depression, "Against Depression," the
earlier book of mine from 2005 is about how we conceptualize
depression altogether. But if we take it as a medical
disorder, we really have to evaluate it as a
medical disorder. That said, I'm not
one of these people who think primary care
doctors do so badly with this.
There has been an enormous effort
on the part of governmental agencies and nonprofits to make general
doctors aware of depression. I think they're better
at assessing it, they're better at recognizing it. And that although we worry about
the overuse of this medicine, on the whole, the fact that
depression is getting recognized and treated is probably
for the good. And I certainly find people coming
to me who've only been treated say by a gynecologist or whatever who
come in and they said, you know, it's not just that I'm a
little better on this medicine, it's that I see my
marriage differently.
I see that it wasn't all my wife
that I had some contribution that there's some loosening up
of perspective as takes place in psychotherapy sometimes in
a good response to medication. So, I'm kind of on the optimistic
side about a broader group of doctors using these medicines because we simply don't
have that many specialists. >> Leonard Bernstein: Sir? >> Yeah. I'd really be
interested in your thoughts on some of the new rapid-acting
antidepressants like ketamine, it seem to have activity
after a single administration.
>> Dr. Peter Kramer: Right. >> And even some reports that
they block suicidal ideation. >> Dr.
Peter Kramer: Right. So, there's a lot of interest in a
drug that was used as an anesthetic and misused as a party drug
called ketamine which is given through injections into the muscle or intravenously dripped
into the veins. And it was first used in people with
very severe hospitalized patients with very severe depression. And some of them got better rapidly.
And drug companies are interested
in this drug and they're trying to get medicines that can be
taken by mouth or can be used as a nasal spray even that would
have some of these effects. And, you know, this seems
like a promising treatment. I'm a little concerned that it's
being used widely before it's well tested. There are some early
worries that people who are-- who do respond to this after
a time stop responding to it and stop responding in ways
that are fairly dramatic.
So, 'we don't really yet
know enough about ketamine. But as I said, there a number
of things on the horizon that seemed to be faster-acting. And the National Institute of Mental
Health has a special pot of money that it uses to encourage research
into faster-acting antidepressants because there's a lot
of risk in the time between when a doctor sees a patient
first and when the medicines work, a lot of risky things
like suicide and other, you know, dramatic negative acts. So, we're very interested in that.
That said, the antidepressants
we have to had now do do things very early. I write about a doctor at Oxford
in England who has used a test of perception, how do you evaluate
kind of pictures and which you ought to see helpful things but
depressed people might not. And he's giving people half
doses of antidepressants, and within three hours,
their outlook changes and their self-assessment. So, there are some early effects.
And one of the theories about
how these medicines work is that they loosen up the brain in
some way, but a lot of what goes on in recovery from the
depression is in the world that is you start calling your
friends again, you start putting in more effort at work, people will
reward that so that there's sort of a virtuous dialectic between
the chemical action and the social and psychological action
of these medicines. But we do get some
effect very early. >> Leonard Bernstein: I
think we have someone here. >> Yeah.
Could you
speak to the subject of how some people have
trouble taking generic forms of antidepressants and when
doctors try to write a note to pharmaceutical companies
to override that, it's been my experience that more
and more often they're rejected. >> Dr. Peter Kramer: Right. >> What is it about the generics? And I know the difference maybe on-- between the generic and the
one that was originally patent.
But I'm just wondering, are
you aware of this as a problem because I see it quite a bit? >> Dr. Peter Kramer: Yes. I mean, doctors worry
when a medicine goes from a company primarily making it
to a generic manufacture making it that the standards of the
Food and Drug Administration for what constitutes equivalence
are either loose or even when they're fairly
demanding that down the road, not enough drugs are retested so
that people on the generic don't do as well as they did when
they were on brand name drug. On the other hand, of
course, we're very worried if doctors are being
influenced by advertising and prescribing brand name drugs and
making medical care more expensive where generics are just as good.
And the answer is it just really
is not enough science on this, but every doctor sees it, you know,
of course where it's dramatic is in neurology where drug
against epilepsy becomes generic and doesn't work as well and
people start having seizures again. You know, you see that whereas
when people kind of fade into having more depressive
symptoms and become more depressive. It's not as dramatic and
as hard to know about. I think with Wellbutrin which is a
drug that works by different means, Bupropion, when that became
generic, there were patients who certainly said they
weren't doing as well on it.
I have patients who are on
the brand name of Wellbutrin. On the other hand, lots of people
do well on the generic when Concerta which is a complicated form
of Ritalin that kids use because it has a certain
curve of release. So, it kind of covers [inaudible]
very well became generic. I noticed in adult patients
that it wasn't working as well.
And the pharmacists reassured
me and then the FDA did say that the generic-- three of the manufacturers weren't
doing a good enough job and they had to sort of rejigger it. But the generic still doesn't
have the same engineering that the brand name has. So, you know, we do worry about that
and it's across all of medicine. And frankly, not enough
is known about it.
It's hard to know what is patient's
anxiety and what is biochemistry. >> That supports what
I've read so far. So, that sounds occurring. Thank you.
>> I see situations
where people say that-- or think that psychotherapy is
ineffective or doesn't exist or seen inadequate in some way. And I wonder if maybe the situation
is that it's very difficult or it's often done
poorly or inadequately. And it's still important to
understand oneself and people in at least a theoretical way. >> Dr.
Peter Kramer: Right. So, I want to extend this question about whether psychotherapy
is always done well and whether people not doing well
in psychotherapy is effective, the expertise say or the match
between doctor and patient rather than inherently psychotherapy not
having a potential be effective for that patient. And I want to take this on a
little slightly different direction which is really antidepressants
have been well tested. And if these complicated critics
where they say well, you know, maybe some studies haven't
been published and we can look at the data and see a
pattern that says that and if we imagine we had
all the studies, they, which are themselves
to be less effective.
And even under those conditions,
antidepressants look effective. But psychotherapy, when it's put to
the same test, really does poorly. It does seem to be the case that
when you study psychotherapy, when people have good results,
they like to publish them, when they have bad results,
they don't like to publish them. So, you get a very
distorted literature.
That said, it's really
hard to test psychotherapy. You don't know whether the doctors
are well trained and you don't have that advantage of people saying,
I don't just like this therapist, I'm going to a different one. You know, in this study, you're kind
of stuck with the person you have. It's free, you're glad
to have it, you know, but it's maybe not the
person you would have chosen.
And maybe it's not that taking
[inaudible] psychotherapy is going to work best for you. So, I think that research really
under measures the efficacy of psychotherapy which I
find, you know, in my practice to be extremely useful and
really, sustaining for people even where they do labs back
into anxiety or depression that the psychotherapy
seems to be helpful in keeping them afloat while they
have a return of some symptoms. So, I'm a big fan of psychotherapy. And I do think it is, you
know, very hard to measure.
Lots of things in medicine
are hard to measure. I mean, I hope this book is
amusing as well as serious. And there are some
amusing things that happen, you won't find this amusing,
but there was a study of these surgical checklists,
you know, where you catechize the doctors and
make sure they got all these sponges out of the patient before they
close them up that, you know, there were these analyses that
combined lots of small studies and showed that 60%
fewer patients died when you're at surgical checklist. And then finally, when they
did a large study in Canada, they required everyone in
Toronto to use the checklist, and the researchers were able
to look at what happened before and after the checklist
were introduced, there was no difference at all.
And probably, the story
was, you know, first of all, maybe they were adopted more
willingly in other places and maybe they're being forced to
adopt and it wasn't as helpful. But mainly, hospital systems
that introduced new methods and had more people die
didn't publish the articles. So, you had, you know, an
enormous bias in the literature. And, you know, I think in
general, I hope in this book, I'm educating people about how to read not just technical
scientific articles but articles in the Washington Post, the
New York Times and, you know, online and all the things
that pass through your Twitter and Facebook feeds, how to
read them skeptically and think if this study had come
out differently, would it have been published at all.
So, yes. >> Leonard Bernstein: I know
we have a time keeper here. Are we-- Do we have
time for couple more? I'm going to go with yes. >> Doctor, you mentioned anxiety
just a moment ago and I wonder if you could talk about
whether treating anxiety as depression is an
effective way to treat it.
And if you've got a very anxious
person who was too anxious to take medication, have you had
experience with a patient like that and how do you address that? >> Dr. Peter Kramer: Right. So, you know, I'm not
writing much about anxiety. But the genetics of
anxiety and the genetics of depression looked very similar.
The reasons why some
people get anxious and some people get
depressed are debated. But they're-- they may well
be out in the world reasons as well as genetic reasons. And these medicines work
well for depression. They are less addictive and
they have less of that sense of you're anxiously coming
off them after four hours than do the medicines uniquely
given for depression like Librium and Valium and, you know,
in the old days, Miltown.
And so, doctors like to get
people on antidepressants. When people are very prone to
anxiety, it can be hard to get them on antidepressants because they can
get more anxious in the short run, and that's very hard to tolerate. And in addition, they may
be anxious about the thought of taking maybe phobic say
or obsessive in some way that prevents them from
wanting to take medication. So, that's sort of an art.
Doctors use very small
doses, build up slowly. But in general, these can
be very good for anxiety. And an area that I
also don't talk a lot about in this book is treating
children and adolescents. And these medicines were less
good at treating depression in children and adolescents.
There may be more risk of suicide. The risk of suicide is very low,
but the multiplication of the risk of suicide by these medicines may be
greater in children and adolescents. And yet, they are used for a
good reason, but where they test that very well is anxiety
in children and adolescents. And it's not that I'm recommending
medicating children and adolescents for complicated story
developing brain but when children really are
not reaching their developmental milestones, they're not
interacting with other kids or they're not learning in school,
they're not able to go to school, you know, it turns out that
these medicines are very useful in anxiety in younger group.
>> Leonard Bernstein: Last two. >> Yeah, hi there. Depression runs in my family and
we're pretty enthusiastic consumers of SSRIs and atypical
antidepressants. But I have a nephew who
wasn't getting better and they did a genetic
test on him and found out that he has a genetic
defect through modification that affects liver enzymes that
make the most the antidepressants completely ineffective for him.
>> Dr. Peter Kramer: Right. >> And he's now being
treated with ketamine. >> Dr.
Peter Kramer: Right. >> I wonder if you can comment on
that and also in the possibility that genetic testing could improve
the treatment of depression. >> Dr. Peter Kramer: Right.
So, genetic testing, there are
already labs that do genetic testing that say that they
can increase the odds that you'll accurately select
an antidepressant for someone. Largely, the genetics we're talking about are the genetics you're
talking about which is enzymes and how the body breaks
down these chemicals. So then if you break
them down very rapidly, you may not be getting
much antidepressant, you've been taking a lot of pills. And if you break them down slowly,
you may be at risk of getting a lot of side effects even on a low dose.
But really what we want, in
addition to that, is the genetics of drug response so that if-- when
you are getting the proper dose into your brain, are you likely
to respond based on your genetics. There is some of that testing, it--
it's at a level where, you know, over just having your doctor choose
it randomly if that where how he or she would choose it, you know, if
you gave 12 people a genetic test, you'd get one more response
than by eyeballing it. Doctors maybe can do better
than random also on their own so maybe 1 in12 is not enough. But I think it-- you
know, it is in the future.
And I think doctors are sometimes
setting off blood samples in really nonresponsive people. The Mayo Clinic, I
know, does some of this. So, it is available, you know,
in these refractory cases. >> Leonard Bernstein: OK, that
seems like a good place to-- >> Dr.
Peter Kramer: All right. All right. >> Leonard Bernstein:
-- to finish off. Thank you very much for being
with us Dr.
Peter Kramer. The book is "Ordinarily Well." [ Applause ] >> Thank you so much. >> Dr. Peter Kramer:
Thank you, good.
>> This has been a presentation
of the Library of Congress. Visit us at loc.Gov..
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