AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2003, Volume 5, Number 10.

Medical Humanities

  • Print

Understanding Psychotropic Medications as Literary Symbols

Training in the humanities helps to provide psychiatrists with an insight into the human condition, as represented in literature, film, and other media forms.

Jonathan M. Metzl, MD, PhD

Fifty years ago, the humanities were considered vital to the profession of psychiatry. Academic journals regularly published articles about literature, art, and cinema. Psychiatrists analyzed works of fiction in presentations at professional meetings as a matter of course. And most important, residents learned about the art of the case study by reading works by Robert Lowell, James Joyce, and other writers.

Psychiatry's focus on the humanities grew out of the assumption that works of art provided entry into the human condition; and that the human condition was psychiatry's province to explore. One avenue of analysis was the (somewhat dubious) practice of diagnosing literary characters, and the authors who created them. For instance, Heinz Kohut described Thomas Mann's Death In Venice as an expression of the author's "unconscious guilt" and "early sexual overstimulation," resulting in an "(ironical) artistic personality." Clinicians also explored the humanities' therapeutic qualities. The use of "bibliotherapy" brought literature into psychiatric treatment, while the notion of the "therapeutic value" of literature, based in reader-response criticism, emphasized the curative aspects of reading. Finally, works as diverse as the movie The Snake Pit and the poetry of Anne Sexton (To Bedlam and Part Way Back) were generally considered to offer important, if not always agreeable, critiques of psychiatry.

In the present day, however, the humanities are often assumed to be less relevant to the treatment of mental illness. To be sure, many individual psychiatrists maintain personal interest in literature and painting. Yet the connection of the literary and visual arts to these practitioners' professional identities is far from apparent. For instance, leading journals rarely mention literary figures; book clubs and fiction reading groups are no longer components of academic psychiatry departments; and literary works are no longer discussed as case studies or examined for the lessons they might impart about interpersonal psychology.

Why are the humanities no longer thought pertinent to psychiatry? Managed care, shorter office visits, and the expanded use of medication are but a few of the changes that rendered close textual analysis, and indeed the case study, obsolete. These factors are also symptomatic of a theoretical shift in psychiatry. Psychoanalysis' historical emphasis on unconscious conflicts and drives found their natural correlate in Hamlet's brooding uncertainty, Anne Sexton's painful reflections, or Van Gogh's manic energy. Such connections between text and context can appear less germane when read through contemporary psychiatry's emphasis on brain biology or genetics.

And yet modern-day novels and short stories provide a plethora of texts in which characters struggle, much like psychiatry itself struggles, to come to terms with life in an era when subjectivity is determined by neuroreceptors and neuropharmaceuticals. Such representations speak to the ongoing relevance of the humanities for understanding mental illness and mental health. Humanities texts and methods can thus help psychiatry understand how its clinical values and assumptions are embedded within larger cultural contexts.

As but one example, selective serotonin reuptake inhibitor (SSRI) antidepressant drugs appeared in nearly 200 works of fiction between 1993 and 2000. Prozac makes a cameo appearance in Meg Wolitzer's romance novel Friends For Life, where Meredith, "lonely and wan," requests "a birthday cake with Prozac icing!'" In Thom Jones's short story "Superman My Son," psychotropic drugs enable Walter's descent into "normalcy." And in Fay Weldon's novel Splitting, Prozac has the power to transform Edwin's father from aging curmudgeon into a 60-year-old love machine: "he started taking Prozac, and six weeks later married that blonde, leather-booted woman." Over this same period, SSRI antidepressants were spoofed in films ranging from Woody Allen's Everyone Says I Love You to Boys in the Hall's Brain Candy. Tank Girl wore a necklace of silver dipped Prozac, and Homer Simpson concocted "home-made antidepressants."

These examples suggest many ways in which psychiatric medications can encapsulate the abstract properties that humanities methods are designed to illuminate. The humanities can help students of psychiatry understand how psychopharmacology contains powers of metaphor, gender, simile, icon, and other functions well in excess of known neural effects. Literature can thus facilitate discussions that will allow students of psychiatry to think of medications not only as facts, but as theoretical symbols.

For instance, Prozac's role in Friends For Life suggests how psychotropic medications can convey socially determined gender expectations. In the novel, Meredith's request for a "birthday cake with Prozac icing" is closely tied to worries that her age will make it more difficult to marry the man of her dreams, while Prozac carries the promise of a drug that will make her more beautiful. Meanwhile in "Superman My Son," medications function as potent brand-name commodities, able to shape symptoms, actions, and ultimately subjectivities in addition to treating them. Jones's protagonist Walter's appearance is controlled by the mood-stabilizing drug Eskalith , his potency by Prozac, and his behavior by Tegretol and Xanax . Walter eventually credits his behavior to the fiction that "the pills have started to work." Similarly in Splitting, medications function as symbols of chemical subjectivity: Edwin's father does not control medication through acts of cognition. Instead, his newfound potency and agency result directly from the Prozac's effects on him.

In these and other cases, training in the humanities can help uncover assumptions represented by psychiatric medications. Such awareness has the potential to deepen doctor-patient communication in an age when, due to shortened office visits and quick medication refills, a formula of "description of symptom leads to writing of prescription" can force psychiatrists to think about pharmaceuticals as the responses to multiple choice tests. So too, humanities approaches can help psychiatrists think about larger implications of pharmaceutical treatments. By focusing on the symbolic value of psych drugs, the humanities can help psychiatrists better understand how medications convey a host of connotative implications in literature and, indeed, in clinical practice . These range from patients' predetermined beliefs about antidepressants to unspoken messages of nurturance at play when doctors prescribe (or chose not to prescribe) medications, to the meanings attached to these treatments by the mass media or advertisements. Ultimately, a psychiatrist's awareness of factual data about psychotropic medications is enhanced by awareness of these complex and often contradictory meanings, and their relation to the larger culture of which doctors and patients both are a part.

Dr Metzl is an assistant professor of psychiatry and women's studies at the University of Michigan, where he also directs the Program in Culture, Health, and Medicine. His recently-published book,Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs, is a cultural history of psychiatric drugs.

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.