NEUROSCIENCE USED TO BE among the least applied of the biological sciences, concerning itself more with memory tests on maze-running rats than with treating the mentally ill. But advances in basic research, combined with changing ideas about the biological basis of mental illness, have worked to change that tradition, forcing psychotherapy to share its place in the clinic with biologically-based drug treatments. The rise of the antidepressant drug Prozac to superstar status in the early 1990s announced to the world that pharmacological therapy for mental illness could be very effective -� and very profitable. Now, brain scientists both within and outside of the pharmaceutical industry are working to develop new treatments: drugs that improve memory in aging and Alzheimer's disease, drugs that suppress excessive appetites, drugs that reduce the detrimental effects of stress on the brain.

These new drugs have the potential to help many people who are in desperate need of treatment. But they also have the potential to help people who are not so desperate �- people who might seem perfectly normal might also use these drugs to improve their memory, lose weight, or become happier. Psychiatrist Peter Kramer coined the term "cosmetic psychopharmacology" to describe this phenomenon, and in his 1993 book Listening to Prozac, he explored this issue, as well as other ethical questions raised by the use of psychoactive drugs. His starting point was a surprising clinical observation: when he prescribed Prozac to patients who were only mildly depressed, the patients occasionally responded so positively to the drug that they felt "better than well." He realized Prozac was doing more than just treating their depression �- it was evoking subtle changes in their personality and behavior that allowed them to function better in our culture, but which might not allow them to function better in other cultures with different values. He also noticed the tendency, in himself as well as his patients, to begin viewing apparently innocuous personality traits as pathological if they happened to disappear following Prozac treatment. These observations raise difficult questions: does Prozac really treat depression, or does it just turn people into conformists? Should we allow the use of drugs that alter personality? Does the use of psychopharmacological drugs encourage us to begin labeling normal characteristics as pathological?

The clear effectiveness of Prozac in treating clinical depression, an undeniably debilitating disease, may have blunted the edge of some of the ethical questions it raised. But since 1993 we have seen some new developments that raise the old, troublesome issues -- and possibly in more worrying ways. Fen/Phen, a psychopharmacological drug cocktail that suppresses appetite, became a wildly popular weight-loss craze; later, Viagra took the country by storm. And just last month, the FDA approved a new diet drug to replace the now-banned Fen/Phen, prompting internet weight-loss doctors whose business used to depend on sight-unseen Fen/Phen prescriptions to get back online. As neuroscience research advances, and drug companies begin to apply these advances, there will only be more examples of drugs that raise ethical questions �- questions about treating normality, about balancing the needs of the patient with the needs of society, about how to know when pharmacological manipulations of the brain are ethically permissible.

Recently FEED talked to Peter Kramer about the future of psychiatric pharmacotherapy, and the discussion touched on many of the above questions. He thinks society needs to formulate cogent answers before the avalanche of new drugs makes further debate moot. But he points out that decisions about when drugs are appropriate will always depend on somewhat arbitrary social conventions and aesthetic considerations. We should come to terms with what we're aesthetically comfortable with and formulate a policy, he reminds us, because once the ethical issues have been dealt with, the potential benefits of these drugs will make them "a boon to mankind."

Read the interview.