Framing Questions

Just beginning Ordinarily Well: The Case for Antidepressants by Peter D. Kramer. A premature post in some regards, in others not. The book is concerned, in part, about how to read; in particular, how we read studies through the lens of mass media. The subject matter forces the reader to be acutely aware of how the questions being asked frame the horizon for the answers the subject matter can yield.

Kramer is most famously the author of Listening to Prozac and has been a practicing psychiatrist for over four decades. He examines insights which emerge in the practice of psychotherapy and the truths which are revealed through rigorous, scientifically measured studies. Some of the questions animating his inquiry are:

• Are insights from clinical practice necessarily limited to being anecdotal?
• Are facts derived from objective studies the only valid source of medical data for clinicians?
• What is the relationship between clinical practice and scientifically monitored studies?
• What is the process whereby specialist information is translated via the mass media?
• How do the issues above impact both therapist and patient in the therapeutic process ?

There are additional questions that will be raised, but addressing the issue of whether or not antidepressants work, per the title, ordinarily well, or are in fact no better than placebos will largely result from the answers to the queries above. What we ask of ourselves as readers is neither simply objective or subjective; it goes to the core of our lived experience and reading background. Just as Kramer forces himself to be aware of his own limitations of understanding, so do I as a reader have to understand my own constraints with regard to both lived life and a limited understanding of the neuroscience that is part of addressing the issue of the efficacy of antidepressants.

Of necessity, I find myself closest to the role of clinician; I can read and understand anecdotally with my experiences in therapy and having been prescribed various antidepressants. Beyond that, the critical evaluation I can foster is with my background in philosophy and logic. At a minimum, these tools at least allow me determine the validity of the arguments being presented.

The ultimate merit of logic as a method is that it can be used independently of the subject matter being evaluated. In a very real sense, the facts are the facts. The veracity of individual claims is grounded in empirical verification and repeated studies to augment the probability of the facts being tested. But the relationship between facts as premises and deducing conclusions from them belongs entirely to the science of logic. The rigor of their validity is independent of the truth of the individual facts. But again, the context for even this putative objectivity is determined by the questions asked in reading the text.

Reading is a significant issue for Kramer as well. In the preface he observes that though he is a practicing psychiatrist, he reads the studies in his field as literature. Beyond indicating that this intends an element of interpretation, he doesn't disclose, (the writing of the book will implicitly do that), what he means by this. But he does articulate why he reads this way; as a clinician he must be pragmatic; the studies are not ends in themselves but information sources to be applied in the context of attempting to aid patients. For Ordinarily Well, the principle issue is how to apply the data derived from clinical trials in the treatment of depression. This issue moves from pragmatic to existential with the invocation of the voice of the patient.

Just as Kramer will examine both anecdotal information from the clinic, so too will he read the experience of patients from his clinical practice and as subjects of clinical trials. Again he notes he reads this as a work of literature and to that extent the patient is a character in the work. The patient is a character with two narrative modes; the voice of the clinic and the general correlation derived from clinical trials. A unifying element of the dual voiced patient is a set of questions revolving around evidence. Specifically, the questions of evidence include:

What it is?

Where it is gathered?

How it is processed?

What forces might distort it?

How a clinician incorporates it into practice?

These questions, along with Kramer's claim that he reads the data of his field as literature lead to an additional set of questions that Ordinarily Well must address.

• What does it mean to read the scientific material as literature?
• Do those that contend the contrary position to Kramer's read the scientific narrative differently?
• Is reading scientific narrative as literature an outgrowth of being a clinician?
• If one is solely a researcher, does one not read the data as literature?
• What rules or principles are involved in reading the scientific studies as literature?
• How does it differ as a methodological approach to reading the subject matter?

The best gift a reader can present to an author is to attack not only their book but the reader's own principles. The merit resides not in having the courage of your convictions but a focused attack upon those convictions; such an approach yields a better reader of the author and raises questions that otherwise would remain muted.

With abundant questions determined, a plan to read is set. As Kramer notes in the preface, the ultimate issue of the book is whether or not antidepressants actually work. Does the evidence, whatever that might be, support the contention of their efficacy in treating depression or are they in fact no better than sugar pills?