Prozac and Atypical depression

This article addresses the relations between ‘nature’ and ‘culture’ (and those characteristics associated with ‘the natural’ and ‘the cultural’) in the context of the debates about Prozac. Following Marilyn Strathern, 

I focus specifically on the contested issue of enablement - that is, on what Prozac does or does not enable, and on the relation between enablement and enhancement, normality and pathology. I argue that the implications of the model of the brain that accompanies explanations of Prozac are such that commentators are obliged to address not only the nature of normality but also the nature of nature itself. Through a close analysis of these debates, I suggest that critiques of Prozac should be understood not as objections to reductionism - to a biology that closes things down - but rather to one that opens things up: that opens up the relations between nature, culture, biology and the individual, relations that are now cross-cut and thrown about by artificiality. Objections to Prozac, then, might be characterized as an attempt to put these concepts back into their ‘proper’ positions, to re-establish the relationality between them. In conclusion, I argue that the biology put forward by proponents of psychopharmacology, regardless of the desirability of the latter, challenges not only the frequent assumptions that are made about the claims of materialist science, but also some of the terms and concepts that are commonly deployed in the social sciences.

Key words artificial, biology, natural, normal, Prozac

... a new set of representations is taking shape; one that places us as an experimenting living being among always-already-experimented-upon living beings. Hence scientific interventions appear not as unique acts of power interpreted as the domination of nature but as a search for an appropriate use of power as capacity, enablement. (Rabinow, 1998: 177)

If there is nothing that is not created by choice, one has to take away the given status of the materials themselves. Take away the inde­pendence of the background against which the choices are made. (Strathern, 1992: 42)

The day after Eli Lilly’s main patent on Prozac expired, on 8 January 2000, an article appeared in the Independent on Sunday with the headline after prozac (Kohn, 2000: 14-16). A rash of competitors is anticipated; Lilly is expected to lose its stranglehold on the antidepressant market; a third gener­ation of antidepressants - ‘as selective as magic bullet mythology ever could have wished them to be’ (Healy, 1997: 175) - will target not serotonin, but noradrenaline (Reboxetine), or serotonin and noradrenaline (Venlafaxine), or ... While Lilly may have lost part of its patent, the ‘wonder drug’ has never­theless delivered, and continues to deliver, its wonder sales. Despite muted expectations following its launch on the US market in 1988, by 1990 Prozac had generated more revenue ‘than the combined amount spent on all types of antidepressants’ preceding it (Lyon, 1996: 58). By 1994, it was said to be ‘the second most commonly prescribed drug’ in the United States, after Zantac, an ulcer remedy (Wurtzel, 1998: 296). The 1994 figures, which sug­gested that 11 million people were taking Prozac worldwide - six million of them in the USA (Lyon, 1996: 58) - had risen to 38 million by 1999 (Boseley, 1999: 13).

Despite the number of available or promised ‘smart drugs’ which currently proliferate, Prozac maintains not only its sales figures, but also its iconic status as the first of this recent wave of ‘designer’ drugs, the handmaid of a ‘new’ era (Kramer in James and Camden, 1993: 14). It is for this reason that I take it as my starting-point. Icons, Aaron Betsky (1997) argues, are ‘magnets of meaning’, objects around which meanings cohere.1 Like other contem­porary icons, Prozac was made rather than born2 and it has a ‘wow’ factor, creating as much noise as it does communication (Betsky, 1997: 23-9). Indeed, Prozac has had a very noisy career to date, a celebrity career, Peter Kramer argues: ‘renown, followed by rumors, then notoriety, scandal, and lawsuits, and finally a quiet rehabilitation’ (Kramer, 1994: xvi). The interest and controversy surrounding Prozac extend from its relation to what Peter Breggin (Breggin and Breggin, 1995), in conspiratorial tones, calls the ‘psy- chopharmaceutical complex’ (an association of government agencies, pharmaceutical companies and professional and philanthropic organizations, as well as insurance companies) to the part it might play in the contested relation between psychopharmacology and psychotherapy.3 Like other icons, Prozac ‘creates what stands in for a sense of community’ (Betsky, 1997: 39); it is the vehicle, for example, through which the ‘Prozac generation’ - a brand rather than a breed, as Elizabeth Wurtzel puts it (Wurtzel, 1998: 32) - constructs and analyses itself, and through which it is constructed and analysed by others. This is a generation whose characteristics are defined, as others have been, at least partly in relation to the state of the (in this instance, US) economy (Brown, 2000).4 Climbing unemployment and rising inflation have given way, Margaret Lyon argues, to a parallel ‘psychic slump’ (Lyon, 1996: 60), and so too to Prozac persons (Slater, 1999: 56) who populate a ‘Prozac Nation’, ‘the United States of Atypical depression’ (Wurtzel, 1998: title and 297). These are people schooled in the language of biochemistry and for whom ‘biological notions have provided badges of identity.... People identify themselves as catecholamine persons or 5HT persons and as bio­logically oriented rather than socially oriented’ (Healy, 1997: 164).

But Prozac has not simply enabled another handful of identities to be mar­shalled under the auspices of biosociality (Rabinow, 1992).5 Perhaps more significantly, this green and creamy pulvule (as Eli Lilly describes it) has con­tributed to the emergence of the brain as an organ of public fascination and to the wide dissemination of a particular understanding of the brain, one whose implications extend well beyond an analysis of atypical depression. As David Healy argues, since the link between neurotransmitters and mood and behav­iour was first outlined in 1955, and was consolidated (particularly in relation to atypical depression) in 1965, ‘a great many researchers poured over this bridge’ (Healy, 1997: 148) with more or less startling claims as to the relation between the brain, biochemistry and the self. It is for this reason that I begin not just with Prozac, but specifically with Peter Kramer’s Listening to Prozac (1994), because this is the book that most notoriously established just such a relation and that has galvanized a great number of critics and commentators to ask again what it is to be human6 - and to ask, in particular, whether ‘human­ness’ is located in the sphere of ‘nature’ or of ‘culture’.

Certainly, in the context of Prozac, biological and sociological (as well as other) analyses of identity proliferate, and many of these explanations fre­quently rely on notions of nature and culture.7 What is of particular interest, however, is that references to ‘nature’ and to those characteristics tradition­ally associated with ‘the natural’ are not confined to biological explanations just as, conversely, references to ‘culture’ and to those characteristics tra­ditionally associated with ‘the cultural’ are not confined to sociological (or other, non-biological) explanations. As Marilyn Strathern argues, ‘trying to sort out the relative weight’ to give to things cannot work because it ‘would fail to register a most significant cultural feature of present life: there is more of everything’ (Strathern, 1996: 46). That is, ‘[t]here is both “more” nature and “more” culture in people’s discourses. I would even say that what lay people regard as science seemingly produces both more certainties and more uncertainties’ (Strathern, 1996: 46). It is not my aim, therefore, to explain away the biological elements in these debates. On the contrary, it is the bio­logical dimension of Prozac, and especially the (popular scientific) theory of the brain with which it is associated, that is integral to some of the most challenging debates and implications that the drug has given rise to. This is neither to ascribe a truth-value to this dimension (because it is biological), nor is it to bracket off that value (either because it is biological or because it is popular).8 Conversely, it is clear that it is not just social scientists but a wide variety of commentators - and I would at the very least add journalists and scientists to Strathern’s commercial managers - who address themselves to ‘how persons are "constructed" (Strathern, 1996: 46).

My intentions are not to try to establish the boundaries of the relationship between ‘nature’ and ‘culture’ therefore, but rather to consider the different ways that these concepts (and the concepts that are traditionally perceived to be associated with them) are deployed in explanations of Prozac, and to what effects. I want to suggest that on account of the nature proposed in these debates, it is precisely the distinction between ‘nature’ and ‘culture’ that is disturbed. And because it is this distinction specifically that is subject to agitation, the claims made by materialist science, and especially the claims it makes for and about the self, demand more than a constructionist/construc­tivist rejoinder (the kind of rejoinder that often amounts to a rejection of ‘science’ and/or its absorption into the social and cultural). In short, the problem that I am interested in (if it is a problem) concerns the status of some of the props that support even the idea of a relation between ‘nature’ and ‘culture’, the props that constitute and maintain the distinction between them and on which their relationality depends. It is this that I want to explore in this article.

My point of entry will be the different ways that commentators who address the implications of Prozac understand, collapse, challenge and/or seek to distinguish between two terms in particular - enablement and enhancement. I have chosen this focus in part because, if the controversy around Prozac can be summarized at all, it seems to me to turn on the ques­tion of what Prozac is perceived to be able to do, that is, what it does (or does not) enable. This is an especially fraught issue where Prozac is concerned because it is often characterized not as a medication but as a ‘mood bright- ener’. Indeed, situated somewhat provocatively in the already opaque (and perhaps arbitrary) area between a medical and a recreational drug, Prozac has licensed entry to a group of ‘therapies’ or ‘treatments’ sometimes dubbed ‘enhancement technologies’ (see, for example, the Enhancement Technolo­gies Group and especially Parens, 1998). For Peter Kramer, this association with ‘enhancement’ is relatively unproblematic because, for the most part, he assumes that enhancement and enablement are synonymous. Prozac, he argues, makes people ‘better than well’ (Kramer, 1994: xvi). Not so for his critics, however, who question not only what constitutes ‘well’ but also what exactly it is that Prozac is said to enhance. They question whether the enhancement or intensification of ‘well-ness’ necessarily leads to enablement or whether, by contrast, Prozac might offer too much of a ‘good thing’ - so much of a good thing, in fact, that its effects should be understood to be dis­enabling. Prozac, it seems, can certainly do something, but what that some­thing is, is a point of considerable contention. It is here that the debate around Prozac meets that of normality (is it ‘normal’ to be better than well?) and what is or is not natural (is it ‘natural’?). These issues are further exacerbated in the context of Kramer’s account of biological processes in the brain, which, along the way, rather casually knocks ‘nature’ from its ‘natural’ place. It is this, I would argue, the knocking out and about of concepts from their ‘natural’ positions, that lies at the heart of the Prozac debates.