History of Psychiatry with Peter Kramer

Dr. Peter Kramer: So patients would come back and say, I’m not depressed again, but I was better at negotiating at work or I was a better parent on the medicine. Would you put me back on the medicine for that effect? absent, you know, any recurrence of depression. And I thought that, you know, it’s a very interesting question: should doctors do that? Why are doctors the gatekeepers for that? Um, we’d be very happy to do that through psychotherapy, with even without depression, right? To make people better parents, better negotiators at work, uh, why are we reluctant to do it with medication? So that question is really heart of the book.

[00:00:34] Guest Introduction
Bruce Bassi: welcome to the Future of Psychiatry podcast, where we explore novel technology and new innovations in mental health. I’m your host, Dr. Bassi, an addiction physician and biomedical engineer. Today we are with Dr. Peter D. Kramer. Dr. Kramer is a renowned psychiatrist and author who I feel so honored to talk to. He’s best known for his 1993 national and international bestseller, Listening to Prozac. This book became what the New York Times called a “signature cultural artifact of its time” that helped reframe the context in which patients and physicians thought of as what was then a new drug class, the SSRIs. So we’re going to do something a little different that I’ve ever done on this podcast, and that’s talk to a historian about the future. If it’s safe to call you a historian, hopefully that didn’t become, uh, pejorized at all.
Dr. Peter Kramer: Yeah. Well, I mean, I’ve written a Freud biography, so I’m a bit, and, and you know, my third book, should you leave is about quirky psychotherapies that were built around quirky psychotherapies that were, practiced probably mostly in the sixties, seventies, eighties. So, you know, there’s some historical app, but I don’t want to be a historical artifact myself
Bruce Bassi: Not an artifact for sure. but as You know I think the names of certain variables change, history for the most part can repeat itself. new innovations are released and ideas discovered and society follows pattern of excitement, skepticism,
disillusionment disillusionment and acceptance with, with different technology, even though the technology and medications change.

Dr. Peter Kramer: Right. And I think we’re, you know, a little bit Marxist in the sense that we think technology frames our sense of the culture, our sense of ourselves. So we’re quite responsible to popular prevailing technologies. I’d say AI now is maybe more in the position of Prozac than even the psychedelics or ketamine, but there certainly is movement terms of what public’s interested in.

[00:02:25] Depression: Past and Present Perspectives
Bruce Bassi: in your introduction in the re release of Listening to Prozac, you mentioned patients with fewer and lesser depressive symptoms were seen as ill and prescribed for. And you mentioned in one of your interviews that the depression that you saw in the 70s and 80s, people were notoriously thin with stereotype movements and Very ill appearing and a psychiatrist may want to know how many holes are now open on the patient’s belt and that was very descriptive for me to think about. So it’s clear standards have changed with what we perceive as somebody who needs a mental health treatment. Why would you say that is? are your hypotheses on that?

Dr. Peter Kramer: think you’re actually speaking about two trends. One is that depression just looked different. You know, the typical depressive was someone who was aesthetic. They, they were not eating, they had pulled their belt in. And, very slowed down. You know, I think nowadays we have lots of overweight depressives.
In those days, atypical depression was depression, which you ate too much and slept too much. The typical depressive not eating and not sleeping. So I think the syndrome has changed some, as happens to psychiatric syndromes. the other thing, which I think is to a small degree due to listening to Prozac is that we count things as symptoms that were a little bit external the disease past, so that when I was writing listening to Prozac, if you had an episode of depression where you weren’t eating and sleeping you were having suicidal thoughts and, uh, not enjoying, not able to experience pleasure and slow down, uh, and you got over that episode and you emerged. pessimistic, self doubting, um, with low self esteem. We thought the medicine or the psychotherapy had done its job. You were done with the episode of depression. Whereas because these SSRIs Almost primarily treat the social anxiety, the low sense of self, low self esteem and so on. I think more and more doctors to consider an episode of depression ended want to see those more personality centers, aspects of the disease gone. So there are two things that have happened. I think we’ve, we’ve, the, the presentation of patients has changed and our notion of what count as depression has changed, even as the official definitions have changed very little.

Bruce Bassi: Do you think as a consequence of trying to reduce stigma, and a byproduct of Talking about that more our threshold to diagnose individuals or have those individuals reach a level of awareness that they have an issue, even though that’s still a problem for a good majority of people, is that an unintended consequence of trying to fix that problem?

Dr. Peter Kramer: Yes. I was in the Carter administration in public mental health and one of the great hopes was to get primary care doctors to recognize depression. It was so under recognized and also, although I don’t think we were centered around this word to destigmatize it so that people could recognize it themselves and present for care.
Listening to Prozac was about a very narrow issue. It was about these new medications and, came out of my noticing or patients pointing out to me that as well as ending episodes depression or decreasing obsessionality, which some patients being treated for these medicines seem to make people, more confident, give them more social ease that there were these personality effects.
But I think the public took the book, even though it wasn’t about this topic, especially to be about depression in general. And it was part of this wave books or testimony that depression more discussable. dated to, darkness visible by William Styron, whom I came to know that way, you know, writer to writer.
But, there were, you know, a number of books after my book, Prozac Nation came out, with Elizabeth Wurzel. So you had these range of depressions being discussed. Mine where there were these, Aspects of shyness and low self confidence. Styrans, sort of an old man’s slow down depression with alcoholism. And Elizabeth Wurzel’s sort of sexually active, sort of agitated depression, I would say.

Bruce Bassi: Let me share another excerpt that I think is particularly relevant to what we’re talking about now. You said, “certain good responders, as I called them, became less bound up in themselves, more comfortable and confident socially. They wondered, some did, whether elements in their makeup, ones that had acted as impediments, like compulsivity or low self esteem, were mere biological happenstance. It was as if patients were listening to the medicine, hearing it tell them something new about themselves, which speaks to the change in personality trait that you’re describing now. And then you mentioned in one column I discussed a patient’s report that on Prozac he was better than baseline or better than well, more solid physiologically, or psychologically you said than he had been before this episode of depression. In another I speculated about what It might mean if psychiatry could tweak personality in ways that patients find desirable, or that the culture rewards, as doctors, would we engage in what I call cosmetic psychopharmacology.”
That’s really, really well put. couldn’t have explained it any better than those two paragraphs there.

Dr. Peter Kramer: yes, I mean, I, wrote, in the eighties, a column, a monthly column in psychiatric trade paper. And those issues that you mentioned, I discussed with my colleagues in those columns, and they were the basis the book. I mean, they led to the offer to write such book to publication of the book.
And I think. You know, you’re mentioning two responses. One is letting response to a technology, letting response to a medication define what’s essential to you and what’s your happenstance. And I had one patient who said she was herself at last on the medication. And I thought if this technology had never been developed, would you have spent your whole life and never been yourself?
What is it to be yourself? And I mean, I think we understand that. that. is, if you had a, Chronic migraine and we’re in pain all the time and a medicine relieved the pain You would feel you were allowed to live as yourself at last, you know free of migraine and I think chronic Recurrent minor depression has that quality of seems like when you are relieved of yourself at last

Bruce Bassi: It’s a perfect analogy, I think. clinically as a practicing psychiatrist that when, you know, we’ve treated the depression, they’re in remission, full remission, we’re thinking about coming off the medications now after nine, 12 months. And then a few months go by and some percentage, don’t reach out to me again and a success.
And other individuals might say, I don’t have depression now, but I just liked how it was doing better previously on the medication. So most of their threshold for wanting to be on the medication has gone down the more experience they get with an SSRI. interesting, and it happens more than just chance. it seems like it happens quite often actually.

Dr. Peter Kramer: yeah, so this was where I left off and, didn’t have the second thought, which is the other thing that I wrote about in these, columns for doctors, and then, uh, made central to the book was the idea that people were better than baseline they said they were doing better, even than they had been doing before the episode depression.
And I wonder what it would mean for medical practice, for medical ethics, if we could reliably tweak temperament to give people a self that was more socially rewarded or better desire than the one that had and whether we would do that and in practical terms, just what you’re saying was really the stimulus for that thought.
So patients would come back and say, I’m not depressed again, but I was better at negotiating at work or I was a better parent on the medicine. Would you put me back on the medicine for that effect? absent, you know, any recurrence of depression. And I thought that, you know, it’s a very interesting question.
Should doctors do that? Why are doctors the gatekeepers for that? Um, we’d be very happy to do that through psychotherapy, with even without depression, right? To make people better parents. better negotiators at work, uh, why are we reluctant to do it with medication? So that question is really heart of the book.

[00:09:44] Are SSRIs Following Tylenols Path?
Bruce Bassi: Yeah, and like your analogy earlier that you gave pointed out, I think there’s a pretty wide gray area in terms of where do you draw the line between what’s an amenity in our society versus what is something that we’re using as maybe too much of a crutch. We can get by, um, without it and maybe we shouldn’t actually use it and it’s, it’s maybe helping us a little bit too much. And then there’s, you know, you could think of, Uh, we go to the grocery store, like that’s, that’s a huge amenity that we, a luxury that we have these days. We have cars, we have airplanes, uh, we have computers that let us do things much more efficiently and fruitfully and with more, more vigor. and you know, somewhere along the line does like Tylenol start to inch into that spectrum? 
And then, what’s next after Tylenol are the SSRIs kind of landing over there?

Dr. Peter Kramer: Yeah. So Roz Chast, when Listening to Prozac came out in response, did a sort of listening to Tic Tacs, listening Tylenol, uh, kind of three part cartoon. Of course changed personality through alcohol, people who. pre drink before a pre game before a party.

[00:10:49] Peter Kramer’s Last Book
Bruce Bassi: Yeah, it’s interesting ethical dilemma. And I, think you were mentioning in your most recent book, you were processing some of the ethics behind psychiatry. Tell us a little bit more about what that latest book goes into.

Dr. Peter Kramer: right. So I have a novel that came out last year in twenty three called Death of the Great Man about a psychiatrist who was coerced into treating an imagined buffoonish, narcissistic, autocratic national leader in the United States, who is in his disastrous second term. It’s a slightly dystopian sort of political thriller, murder mystery.
I mean, it’s meant to be a literary fiction, but it has, it starts with this great man dead on the psychiatrist’s couch and the psychiatrist has to go on the run and explain what the lead up was. But you know, the ethics of the air is what goes into treating an extremely dislikable, unlikable patient.

And what goes into treating some, someone who is harmful and powerful, what the ethics are, you know, where does the Hippocratic oath take us in that case? So that, that’s the function of that book.
It really comes from clinical experience because if you do clinical work at all, you will treat some very difficult patients. And I had done some forensic training, so I’d worked in prisons and, you Got know people who’ve done some fairly difficult, you things that were difficult to like or forgive. so that is part of what we do. know, going back to the other issue when you were saying my last book, I thought about Ordinarily Well, which was my last nonfiction book, and it deals with the claim that Antidepressants, particularly new antidepressants, are a little more than placebos with side effects, which think is clearly false, and I a sort of detailed argument about what the evidence is that these medicines work.
Oddly, the topic we’ve been talking about, whether these new antidepressants make people more assertive socially, is really not challenged in same way.
And we would just see throughout the animal kingdom that you expose animals to medicines like Prozac and often it’s Prozac that’s used, they become more alpha in their culture so that the lobster near the food supply will be a high serotonin uh, these medicines make the brain more effective in the, uh, In the use of serotonin and the lobster near the food supply will be a high serotonin lobster. You can artificially create different leadership roles and monkey colonies by altering the monkeys brain access to serotonin and their problems.
Now that we have. serotonergic drugs in the water supply, because people flush their pills or just because it comes out in the urine. you have crayfish being too bold because they’ve been exposed to Prozac, and, you know, risking, being captured by whatever predators are. So this is really across the animal kingdom.
I mean, it’s an earthworms, it’s birds that eat the earthworms. We are to an extent, creating alpha status and animals through wastewater.

Bruce Bassi: Is there any sort of biological correlate in humans where people are tapping into their native dominance tendencies from that? Or do you feel like people, humans in particular, have the ability to inhibit those more innate tendencies and drive?

Dr. Peter Kramer: don’t think we see as consistent results in humans. There are a few of these studies where people are given Prozac and put in group negotiating positions and they seem to take more of a leadership role and it seems to be a complex leadership role where it’s assertive without being aggressive. There’s some to negotiate.
But I think in general, human psychology is so complicated that just tweaking one part of it probably Usually overwhelm the system. I mean, the, exception is if people become manic or almost manic, hypomanic, and there’s a great debate in psychiatry about the extent to which, or even whether antidepressants, tend to throw people into mania or make people who were cycling cycle more quickly.
but, you know, there certainly seems to me are some patients a little revved up on these medicines.

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[00:15:44] SSRI Perception Evolution from Last 5 DecadesBruce Bassi:
If you were to give me one word to describe society’s perception of SSRIs in each decade, from the 80s, 90s, 2000s, 2010s, 2020s. What would you, kind of want to understand from you like the arc of SSRIs and how the trajectory has changed over time. Let’s see if we can apply it to any newer options.

Dr. Peter Kramer: yeah, I it’s an interesting challenge. When I wrote Listening to your Prozac, there already had been celebratory articles and debunking articles so that very quickly in the course of three or four years, you’ve got this whole, parallel to, you know, Hollywood celebrity status where people’s virtues were seen all at once.
And then there. Shortcomings were highlighted, but I think there has been a slower, you know, more slow motion arc also that, when I listening to Prozac, there was at least an openness on part of readers to, think that these drugs could make substantial differences in terms of how people function, and that they were mostly for the good.
What was In a way, kind of remarkable about these drugs was how few acute side effects had. So in the first few years, yes, there were a few people who probably became more violent or more suicidal on these medicines, but they were you know, very infrequent side effects. And, there were a few reports and some of the reports didn’t sound to be actually thing that was being alleged.
So it was complicated, but on the whole, I think what made these drugs popular, what made them widely prescribed was that they seem to operate sort of in the background, and that the main effects were the antidepressant personality effects. in recent decades, there’s been a ton of skepticism.
I think some of it comes from a general anti psychiatry movement, because psychi you know, there’s no anti cardiology or anti nephrology movement. It’s because mental health professions are so divided among psychiatry on the one hand and psychology, nursing, and, social work others, on the other side because we like for melancholy to be psychological and don’t like sort of on a preference basis have it something that has a large biological component and it’s largely, uh, can be affected by medicines.
and I think for other reasons, people’s eagerness to believe in placebo effects, people’s wish that the mind really be largely fixable through metal processes. there’s just a lot of opposition to antidepressants and then on top of that, we have social media effects so that there’s sort Prozac survivor groups and people with lots of complaints about longstanding sexual effects differently getting off medication.
And it’s hard to know how frequent any of those negative effects. are, but certainly there are vocal people who are out there complaining about medicine. So, in the new edition of Listening to Prozac, I try to imagine what it would be like to write these exact same words now, because the science largely, the science in Listening to Prozac largely has held up.
The observations are still observations that clinicians make, commonly, the science has progressed in some ways, but it’s not in ways that really contradict what’s in the book. And yet, if you wrote the same book now, you would seem to be a strange person because you’re ignoring this whole tide.
That’s, you know, debunking or pushing against antidepressants.

[00:19:06] Differences While Judging SSRIs and other Drugs
Bruce Bassi: think one unique aspect of SSRIs had to deal with in terms of a challenge in their development and popularization has been that they’ve been so closely linked to pharmaceutical industries and that I think is a challenge that ketamine doesn’t experience, cannabis doesn’t experience that. I mean, nobody thinks of a particular pharmaceutical company when they think of cannabis. And I think people in their minds want to explain or have some sort of subject for their ire, for those long term sexual side effects and they, feel that it has more intentionality or a voluntariness of, somebody wanting to do harm to, culture and two individuals, but it’s interesting because I’m trying to think if ketamine and cannabis and other psychedelics that have been around for ages that don’t have that ability to patent them at this point, if they’re, they’re kind of getting off scot free and they’re not having to deal with that aspect of it. So there’s a little bit of different approach to them versus Prozac.

Dr. Peter Kramer: Right. I mean, I think there are about four or five things on the table. One is that the drug companies did behave badly. they suppress some research. They overemphasize some research in ordinarily. Well, I take the reader into some, into a drug testing facility where the efficacy of new, uh, antidepressants, is tested.
And, you know, it’s a fairly horrible journey. You’re taking people, very poor people, socially marginalized from single room occupancy houses and big cities and, putting through these trials because when you have something like Prozac that’s probably 10 cents pill and is very effective, don’t have any impetus for it.
Physicians to refer their patients for drug trials or there may be patients who’ve done very badly who have not to respond to medicine, but you get mostly these, marginalized people in the drug trials. So drug companies have a lot to answer for. That’s one part of the response. The other is, you know, another aspect is sort of the natural cannabis is natural.
It’s been around a time. You can grow in your yard. And that doesn’t mean it’s harmless, right?

Bruce Bassi: The concentration is not natural of it.

Dr. Peter Kramer: no, that’s true. You’re getting strains of cannabis that nobody ever had before. And, in addition, there’s a industry behind it now, making. cannabis chewable form and form uh, so on.
Psychiatrists don’t like cannabis because it throws people into psychotic states who are sort of on margin. And, it’s not harmless. It’s not harmless in the young and the very people who are. most likely to harmed by it are the ones who probably end up using it the most.
So, but yes, it’s, it has a different valence than pharmaceutical companies like Prozac. Ketamine is sort of a different story. you know, it, it was produced by drug companies, but it’s already on the market and approved for, uh, as an anesthetic.
And I think ketamine is being industrialized in a way that we’re going to look back on with horror as well. You know, that can now order ketamine online. Barely monitored, by someone at a distant site and, I, I think we’re going to find that we overused ketamine as well, but it’s true also, because it’s was a party drug because it has that aura of, being a little bit illicit and not pushed by mainstream pharmaceutical houses.
it has sort of a bad boy appeal, so we’ll see, at the same time, I think it is true that some people really benefit from ketamine treatment who were stymied before.

[00:22:56] Ketamine Particularities and Study Group
Bruce Bassi: Are there analogous treatment that we can look to that has similar characteristics?

Dr. Peter Kramer: Oh, to ketamine? so, I mean, let me say a few complicated things. One is that psychedelics probably are doing something and it is the important part of it may be along the lines of what conventional antidepressants That is, it seems to throw this brain into a state where can learn. And so if depression is sort of a stuck switch problem, or you’re going around in circles, having the same negative thoughts again and again, all these medicines seem to make possible for the drug to create new links and pathways change in some way.
So, and the, so they all probably also do well in conjunction with psychotherapy. Ketamine, there’s one very funny study of ketamine, which I mentioned in the new afterword to listen to your Prozac. All right. Because ketamine is an anesthetic someone had a they took people who were depressed and needed to be given anesthesia for conditions that didn’t inherently involve the brain, so say a very complicated broken leg, and some of these patients in the active group, they would give ketamine in the dose that it’s used in psychiatric treatment, is a low dose relative to anesthesia.
And they’d fill out the rest of the anesthesia need with a conventional anesthetic. In the control group, they wouldn’t give ketamine at all. They’d just give conventional anesthetic. And, after the surgery, they I saw what happened to people and what was funny was that a lot of people did get better.
They got better both on the ketamine and on the non ketamine condition and there was no difference So it’s very hard to do a double blind trial with ketamine, right? dissociative effects. People know they’re on ketamine. If give them a placebo, they know they’re not on ketamine, but here nobody knew whether he or she was on ketamine.
now some people in defense of ketamine have said, well, maybe some of the other anesthetics have antidepressant effects as well. And you know, so it’s not clear what that study shows, but I thought it was a very smart, funny study to get a real control trial of ketamine.

Bruce Bassi: it’s a bummer that the control group did. just as well. That’s really
concerning.

Dr. Peter Kramer: And it’s not the case in general that people come out of surgery with broken legs less depressed. I mean, they, they might, if they get back to some function, feel better, but this was a kind of an unexpected result.

Bruce Bassi: I mean, just merely the positive expectance of somebody, you know, I’m trying to imagine I’m pre op signing up for a study. I may get ketamine. This is a positive thing, and maybe I have a personality trait where I have a higher degree of openness rather than neuroticism. maybe so, influenced.

Dr. Peter Kramer: what’s interesting about that argument is when that argument is made against antidepressants, it sounds very convincing, right? you can give a dummy pill that it does well as an antidepressant, you say, well, the antidepressant isn’t adding anything to make that argument with ketamine, you know, somehow sounds more, more innocent. the placebo question is very interesting and I think, you know, I don’t know how much was done in that surgery study, but when you take people in and you ask them a lot about their psychological problems and you follow up and ask them further questions and lots of tests, you know, their blood pressure and so on, that has a slight psychotherapeutic effect so that people who are engaged in trials of Anything psychological tend to do better, and it’s not clear that it’s the pill or the anesthesia that is having the placebo effect.
It may be that whole social context is just useful for people. There also are interesting analogies outside of therapy, so that if you Take people and tell them that you’re giving them alcohol, which you can’t do today, you know, because of, you know, the ethics of, studies. But back in the days when you could lie to patients in a study, if you gave some people alcohol and gave some people a drink that Tasted like alcohol, they would both get disinhibited.
Well, that’s not a proof that alcohol fails to disinhibit people because it’s also the case if you told people nothing and gave them, you know, a, a drink with a lot of alcohol and they would get disinhibited. the fact that you can replicate some of these effects without the active ingredient actually does not mean the active ingredient is not working.
ordinarily, well, I discuss the sort of math of this or, you know, how you handle that problem, that you can, that some of what placebo does is, you know, or that whole placebo setup can do some things that the active drugs do doesn’t necessarily mean the active drugs don’t work. And you see this kind of effect with drugs for, conditions like, Parkinson’s disease, you know, it’s sort of, as you think would be very hard to affect, you can kind of blur the, apparent efficacy of drugs that really treat Parkinson’s disease, depending on how you set up a trial.

Bruce Bassi: Interesting.

Dr. Peter Kramer: if that’s too complicated, I’d go to ordinarily well, I explained it.

Bruce Bassi: Let’s talk about, public’s perception or expectations of coming off medications, SSRIs compared to the newer options. know, I feel most people, they just have this sense that they don’t want to be in meds. I don’t know why it just like feels like they’re broken or weaker or but You know, unless cannabis causes some sort of issues for an individual, They don’t mind being on it. And I feel like ketamine is also going to get kind of lumped in with that group of cannabis because maybe it’s maybe it’s a degree of trustworthiness or lack thereof of SSRIs and psychiatry in general and maybe People perceive ketamine as kind of coming in from the side and not necessarily by psychiatrists But How is that going to affect individuals who seek treatment?

Dr. Peter Kramer: I think we’re in an interesting moment. I don’t know how much of this difficulty coming off medicine. I saw in my practice, I worked with these medicines, you know, for decades and would more ordinarily have patients come in and say, you know, I was feeling well, I forgot to fill that last prescription.
You know, I haven’t told you this, but actually I’ve been off medicine for two or three weeks and they weren’t complaining about terrible withdrawal effects. They just, came off barely intending to. so I think that was sort of the more common. On the other hand, I mostly, I did have some patients who were on, still are on SSRIs, stopped practicing, but, patients I tried to get off after nine months or a year, so that I was often using these medicines shorter term.
Ketamine, you know, is used. intermittently, right? You’re, you have a couple of treatments in a week and then treatment space by a week and then once a month. And so people really aren’t on ketamine.

Bruce Bassi: actually, there’s a new company trying to develop a long acting ketamine, low dose that can remove or lessen the possibility of dissociative effects. What are your thoughts on that?

Dr. Peter Kramer: you know, I don’t know about that, but John Crystal, who’s the head of psychiatry at Yale and one the initiators of ketamine use in kind of depression, really got this whole movement going. he thinks the dissociation is sort of necessary to the, treatment that dough that you, when you’re not getting dissociation, dose is too low.
So that’ll be interesting to see.

Bruce Bassi: But for that study you just cited though.

Dr. Peter Kramer: Yeah, well, that study may be a non effects study. I mean, that may be, you know, the ketamine is, is really not doing much. But anyway, you know, the patients who knows that the patients were dissociating, they were, they were
out. there is a drug that’s approved for the treatment of postpartum depression and it has been tested for major depression, not postpartum well. And it’s a drug that you take for 10 days that’s it. You take it, it’s related to some of the hormones that change in one of the hormones that changes pregnancy and delivery.
So patients are on this drug for 10 days and then they’re off. And I’ve spoken to some people from the company that makes the drug and they say patients stay well for nine months or a year. So that is going to be a medicine if it it holds up if gets widespread use, where people really are not on medication.
Most of the time they’re getting the benefit from the medication, they’re not on And I think it will be interesting to see what the complaints are in that group. It wouldn’t surprise me if nonetheless, there were, because depression is so insidious, it comes back and bothers people in so many ways. It wouldn’t surprise me if over the course of, you know, at the six or eight months mark, there were, if you really did a survey, those patients had some, physiological seeming complaints that, paralleled I’m just curious.

I think we’ll know how much of the Difficulty over a long term use of SSRIs is really true, dependency with great difficulty getting off and how much has to do with the long term course of depression. I think, you know, there are probably some of the first, but I think we really don’t know. And we have long term use of some of these other alternatives, like ketamine or this, medicine related the female sex hormones, we’ll know more.
You know, what’s what I won’t be around to, to get that answer because you’re going to need decades of exposure.

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[00:34:05] Using AI to Diagnose Politicians
Bruce Bassi: you said that you think the debate about whether or not psychiatrists ought to diagnose mental health problems in politicians would be resolved because AI would just be able to do that for us. Can you elaborate on that? And how do you see that coming to play in the upcoming?

Dr. Peter Kramer: thought about this a lot, writing that novel. So my psychiatrist in death of the great man, Henry Farber is really a psychotherapist. Primarily there’s no medicine used on the great man. and I thought the virtue of the book is it gets you very close to one of these. Dislikable political figures and, Dictatorial. And we’re not too interested in the diagnosis. We want to know the texture. We want to know what it feels like to have hourly and daily interactions with such figure. And I thought the diagnosis part, very strange that we’re so focused on whether, you know, psychiatrists or psychologists are prevented from, calling Trump, know, paranoid or narcissistic or egotistic or, having mild Alzheimer’s or any, any of the things that are thrown at him.
And I thought really the psychiatrists and psychologists who want to make those judgments are relying on. data that is seen from a distance, right? Political speeches, television appearances, policy decisions, whatever it is you used, you know, complaints that other people have about you that make it into the press.
And I thought, this is what AI is really good at, is taking exactly That kind of data and summarizing and, you know, there was some interest in, the finance sector in this sort of thing that when, companies with highly narcissistic leaders were getting into trouble, right? And going bankrupt because they’ve been some, problems in making
Data presentation or, embezzlement or whatever was going on. investors wanted to know the diagnosis of, CEOs And we’re turning to psychologists, to do this. And I thought. Well, why won’t there be a demand for AI to do this? And if you can do it with financial leaders, why not political leaders?
So that was sort of the, the line of thought in that article. But it started with the novel in my sense that the things that people were talking about were sort of gross. you know, psychiatry and psychology to some extent are covered by what’s called the Goldwater rule because when Barry Goldwater was running for president, a magazine asked psychiatrists, whether he was trustworthy and a lot gave him a mental illness diagnosis and, Goldwater sued the American Psychiatric Association, on that, that
And the psychiatric association made this rule you can’t diagnose politicians unless you’ve interviewed them and have their. permission, you can’t do it from a distance. And that took place more in the era of psychoanalysis where diagnosis was very delicate. And I thought contemporary diagnosis, you probably can do it from a distance, but you may not need a mental health expert to do it.
You know, you may just need a machine that’s good pattern recognition. So anyway, it was sort of a funny thought. But it came out of the novel.

Bruce Bassi: You’re saying basically that we could have a machine do it, but what’s the point because we really want to know what the person’s like on a more personal level.

Dr. Peter Kramer: Well, no, I think the point of having the machine do it is, you know, you could warn the electorate that this person is dangerous certain ways. But, as a novelist, it doesn’t matter whether my psychiatrist thought that the great man who is not Trump, you know, he has his own character, you know, whether think that
Paranoid or narcissistic. I mean, the reader doesn’t care at all. The reader has his or her own of integrating, portrayal, you know, the elements that go into the portrayal of a fictional character.

Bruce Bassi: Do you think his supporters would even care if an AI machine said that? I don’t think they would.

Dr. Peter Kramer: No, they wouldn’t. But I mean, I think that, you know, the Claim for psychiatrists and opposing the Goldwater rule was sort of a duty to warn, they had some special knowledge that allowed them to warn the public. and psychiatrists would then be relegated to explaining what the diagnosis means in general.

Bruce Bassi: I wonder if there will be a new rule in 2024 with a different that, well.

Dr. Peter Kramer: people have asked me about narcissism and saying, well, isn’t it just the case that all political leaders are narcissistic? I thought. Well, think about the presidents we’ve had and the presidential candidates are they narcissistic if they are certainly not in the same way? think that we have leaders really are entirely in it for themselves. And we have leaders and who don’t really see anything except themselves. We have other leaders who may. think that they’re due to have a leadership role, but they see the world complexly. They’re capable of having self doubts, they’re capable of seeing two sides of an issue.
So that they’re also covered by narcissism, we’re talking about too large a category

Bruce Bassi: it certainly speaks to the selection bias issue that we were talking about earlier, because you would think out of 300 and whatever million people there are in the U. S., you know, that we would end up with different candidates at some point, but we were repeating the same candidates. So it’s like, who are the people who do want to run? Well, there’s, you know, you have to, I think, narcissism, or at least. a lack of, caring of what people think of you must be pretty crucial and necessary, but not sufficient to become president.

Dr. Peter Kramer: I think the presidents are very different. I think if you think about the confidence that Jimmy Carter had, it was a very complex kind of confidence. And I think you knew. He could be a leader, but he certainly saw the Ewing condition complexly. And I think Bill Clinton’s flaws were little compartmentalized.
He certainly was able to, relate well to people in a way that seemed caring and I suspect was caring. So I think we’ve had a range of personalities. Ronald Reagan always struck me as a little thin, you know, that he was, affable in a way that some people like, but, you know, there was a certain thinness there.
So I think the character types are actually very different and that you lose a lot if you think one diagnosis can cover them.

[00:40:44] Peter’s Perspective on Nowadays Therapies

Bruce Bassi: Yeah, interesting. In closing, getting back to meds and, therapies and whatnot, what therapy on the horizon are you most excited about? If you had to pick, if you had to write
another book about listening to blank.

Dr. Peter Kramer: Oh, you know, I, I don’t have it. I feel like I don’t I was inspired to write about Prozac because I had a psychotherapist view of it. You know, I was practicing psychotherapy, introducing these meds and seeing their effects on a very subtle. And I haven’t had, I stopped practicing and never administered ketamine or the, or the psychedelics, and certainly not these, know, the drugs related to the opiates that being introduced now, drugs, as I say, related to hormones, some others, and I think you don’t know, I think until you’ve worked with a medicine, until the public’s been exposed to it, very broadly, That these medicines really do have personalities and you don’t know what they are.
And I should say also, I’m not especially excited about contemporary psychotherapies either. I think that each era has its therapies that speak the, social concerns. You know, we’re very interested in trauma and deprivation at the moment. you know, not interested in sexual repression as a dynamic.
I think psychoanalysis worked in Freud’s day and I think that these trauma centered therapies, work in our day I’ve always believed this true that the common elements related to the doctor patient relationship, caring, listening, attentiveness, responsiveness that those factors are really The ones that make a difference.
I’ve never been on the bandwagon for cognitive behavioral therapy. I don’t, you know, care, especially about mindfulness. I’m not, you know, you’d have to be a curmudgeon to be opposed to mindfulness, but I’m not, you know, I’m not thinking that it does better than psychodynamic psychotherapy. There’s a, a bad answer. I’m not, I probably a sign of age. I’m not, you know, kind of sparkling in response to any particular medicine or psychotherapy.

Bruce Bassi: Speaking of listening, I, I really enjoyed listening to you today and I appreciate all your insight. I feel like I could talk to you for hours, but hopefully the audience enjoyed it as well. And I will put, the links to your books and how to purchase them if anyone’s interested, in the show notes and the captions, for the episode.

Dr. Peter Kramer: just thank you for a really broad ranging set of, questions
Bruce Bassi: it was fun. We covered a lot of ground here, so, I appreciate it.

Dr. Peter Kramer: me too. Thanks.

Bruce Bassi: That’s it for this episode. I’d appreciate it if you please like and share this podcast with your colleagues. It’d be especially helpful for us. If you’d like, please leave us a rating on your favorite podcatcher. If you’re a clinician, I developed a course on how to start a private practice. And for patients, I’ve also developed a course on acceptance and commitment therapy and cognitive behavioral based therapy lessons for treating and helping anxiety.
You can find all these on our website as well. as well as the show notes and resources for each episode. Thank you so much, and I’ll see you in the next episode.