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'Against Depression' Urges Ending a Disease

Peter D. Kramer's new book is Against Depression. In it, the author of Listening to Prozac puts forth an understanding of depression as a modern scourge. Kramer argues that depression should be considered a disease — and treated as such. Kramer is a clinical professor of psychiatry at Brown University.

30:15

Other segments from the episode on May 17, 2005

Fresh Air with Terry Gross, May 17, 2005: Interview with Peter Kramer; Interview with David Shore and David Foster.

Transcript

DATE May 17, 2005 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Peter Kramer discusses depression
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

In his 1993 best-seller "Listening to Prozac," my guest, Peter Kramer,
considered the impact of antidepressants on people's sense of self. In his
new book, "Against Depression," Kramer writes about why depression needs to be
taken seriously as a disease and treated with medication just like any other
disease. He also explains what recent research is teaching us about the
biochemical nature of depression and what clues that offers about potential
new medications. Kramer is a clinical professor of psychiatry at Brown
University. According to Kramer, one reason why many people are reluctant to
treat depression like a disease is that we associate it with artistic
inclinations and sensitivity, traits we admire.

You say in your book that people are always saying to you, `But if we did away
with depression, would we have had a Van Gogh?' What do they mean by that?

Professor PETER KRAMER (Brown University): I think the worry is that
depression is related to creativity, and in some way that benefits the culture
so that if artists were, say, happy, we would not have some ballast for what
is really an acquisitive, happiness-oriented society. And I think that that
objection mistakes what depression is. I think depression has declared itself
to be disease, and that people who are not depressed have a full range of
emotion and in particular a full possibility of experiencing suffering.

GROSS: Do you think if we did away with depression that we would be doing
away with a certain level of introspection and reflection, and we'd be doing
away with introspection and reflection that we find in the arts? I mean, I
think that is one of the fears...

Prof. KRAMER: No.

GROSS: ...you know, that a lot of people do think that, like, depression and
writing or depression and painting are linked in some way. And in part people
believe that because there are so many people prone to depression who are our
writers and our artists.

Prof. KRAMER: Well, I have, I think, a complex response to this, and I think
to understand the answer one has to have some sense of what depression is as a
disease, what sort of disease it is. But the short answer is I think, first
of all, that optimists can be very thoughtful. They are capable of ambiguity.
They're capable of depth. They know the human condition is perilous. So I
think one does not have to be even a pessimist much less someone who's
depressed in order to understand life's complexity. So that's one sort of
answer.

But the other sort of answer is that it really depends how we would do away
with depression. If we could stop the pathway to depression at the very last
step so that one could experience losses, one could experience pain, one could
even have the genetics that make one vulnerable to depression, and the last
step in the link would be broken, the last link in the chain would be broken
so that one actually never had damage to the brain, one never fell into these
very narrow mood states that last for months and even years, in that case, of
course, eliminating depression would allow us to be highly neurotic, it would
allow us to be highly ambivalent and, you know, somewhat paralyzed without
being depressed, and in effect the treatment for depression would make the
world safe for neurotics or safe for depressives. So I think that's one way
of answering the question.

GROSS: You're talking about a kind of depression that is very extreme.
You're not talking about a few days of not feeling yourself and being sad. So
would you describe the kind of clinical depression that you mean when you use
the word depression?

Prof. KRAMER: At the core of depression is a state where people are really
disabled. That is, they're ruminative. They feel guilty about things they
ought not to feel guilty about. They may be desperately suicidal. They feel
empty and depleted. They have a very narrow range of effect. It's not that
they're passionately sad. They often cannot grieve if they suffer a loss
during the period of depression.

Now the way we make the diagnosis is a much more limited way. You have to
have two weeks of moderate symptoms, and those symptoms include things like
sadness and inability to experience pleasure and sleep, appetite changes and
so on. But it turns out that people who have two weeks of those moderate
symptoms, most such people actually have the more severe thing that I'm
talking about. And that describes an episode of depression. But most people
who have an episode of depression have another one, and most who have two have
many more, so we're talking about what really is a chronic relapsing and
recurring disease.

Now that said, once we fully embrace depression as a disease the way we
embrace arthritis as a disease, then we may have a different feeling about
more minor manifestations. We may worry that a more minor depression is
really a pogrome, a lead-up to major depression. We may worry that it's some
left-over symptoms, that it's a residue of depression that is gonna lead to
more episodes.

GROSS: You want to see depression as a disease, and a disease that hopefully
can be treated. In what sense is depression like a disease as opposed to a
condition?

Prof. KRAMER: It's fully a disease, and I don't think it's a question of my
wanting. It's a question of the facts. I have been under pressure, as you
can imagine, over the past 10 or 12 years to write another book that's like
"Listening to Prozac" and to be on the lookout for a new medication that has
startling implications for our sense of self, and I think what I saw over
those 10 or 12 years wasn't a change in treatments, but a change in this
underlying condition that is in the scientific understanding of depression.

And what has emerged has emerged on a number of fronts simultaneously, and
it's a forceful body of information. The first bit of it is that it looks as
if depression harms the brain, so that's one sort of information. It
disorganizes parts of the brain that deal with emotion, maybe causes atrophy
in parts of the brain that are involved with emotional memory. Another whole
line of evidence has to do with depression's effect on organs other than the
brain, so that depression makes you more liable to stroke and heart disease
and disorders of the bone and blood components. It's really a multisystem
disease that looks a lot like other multiorgan diseases, things like diabetes,
so I think it looks very much like a disease.

And then if you look at the public health information, it looks as if it
causes more disability over lifetimes and throughout cultures than almost any
disease we can name. You know, there was a surprising World Health
Organization-Harvard Public Health School study that, I think, intended to
find that things like infantile diarrhea were, you know, terrible diseases and
we ought to put our money into preventing those in Third-World countries, and
lo and behold, up on the radar in a position very close to the top comes
depression. Surprise to everyone. And it looks as if depression causes more
disability over a lifetime than things like the various cancers or AIDS or
heart disease. It's certainly well in their league.

And even if you change the assumptions that are in those studies, which
frankly are a little favorable to the mental illnesses in terms of, you know,
assessing their severity, if you cut the assumptions by half, depression would
be more disabling than diabetes and asthma combined, and it's true whether you
look at advanced or developing countries.

GROSS: Let's break down what you've been saying here. Let's start with the
fact that you said that depression seems to be related to an atrophy of the
brain. Can you describe what you're talking about there?

Prof. KRAMER: This is not absolutely sure, but there was an astonishing study
that came out in the early 1990s by a very bright researcher, Yvette Sheline.
She looked at women who were extremely healthy. They didn't have illnesses
other than depression, and they didn't even have some of the lead-up
conditions like high blood pressure that make a person vulnerable to illness.
And she looked at parts of their brain with the newest forms of brain
scanning, which are more subtle than forms that were available earlier, and
parts of the brain seemed to atrophy with age, and in particular the
hippocampus--which is of interest for reasons I'll mention in a minute--seems
to get smaller with age in, you know, rodent studies.

And in these women who were extremely healthy, the hippocampus did not get
smaller as they got older, but the hippocampus was smaller if they'd had more
days of depression, and there was a linear relationship. The more depression
you'd had, the more days of depression a woman had had, the smaller her
hippocampus, and there were similar results in another part of the brain
that's involved with emotions as well, the amygdala.

So that was a very scary finding, and she later went and revised that study
and looked at days of depression when a woman was not on antidepressant
medication, and the fit was even better. So it was untreated depression that
correlated with smallness in the hippocampus. So it was lifetime exposure to
depression that was relating to the small hippocampus, and there was a related
loss of verbal memory. So it looked like depression was doing two things. It
was attacking the brain or there was some other possibility that starting with
a small hippocampus wasn't good, and in addition it looked like it was
interfering with repair mechanisms. So depression was looking both like a
vulnerability and like a paralysis of recovery.

GROSS: So what would it mean to have a smaller hippocampus?

Prof. KRAMER: Well, it would mean a number of things, but in particular the
hippocampus is also involved in ending stress responses, so that there's a
cycle that goes on when you're under stress acutely, which is you mobilize
your fight-or-flight response and you have stress hormones coming out of
certain glands like the adrenal gland, and you're ready to face the challenge,
and then the challenge goes away and the switch goes off and you recover.
People who are exposed to these stress hormones over a long time suffer all
kinds of problems. If you have Cushing's disease you have too much of these
adrenal hormones, for instance.

And people who have depression look to be in that state. That is, they have a
stuck switch and there's this vicious cycle, which is to say that if you're
damaging the hippocampus, the very part of the brain that's meant to shut off
that switch is now damaged, so that the stress response is more and more
prolonged, and with exposure to those stress hormones over time, it may be
that other parts of the brain come under attack as well, and there's a part
called the prefrontal cortex that probably is also implicated. It's another
part of the brain that looks disorganized in depression.

GROSS: The stress response affects all kinds of other organs in the body.
Want to talk a little bit about how, therefore, depression might affect other
aspects of your health.

Prof. KRAMER: Yes. Depression looks like a multiorgan disease. What
happens when you have a chronic stress response and you have this stuck switch
and you're not able to turn off the stress response is that your adrenal gland
grows larger. The result of having all these adrenal hormones flowing around
is that your bones lose calcium so that women who have had chronic depression
and are not yet menopausal look more like postmenopause women in terms of
fragility of their bones. Your platelets are ready for you to be wounded as
if you were about to enter a fight, so the platelets, the blood platelets,
these elements that are involved with clotting, become more sticky, and that
makes you more vulnerable, probably, to strokes and heart disease.

The results of this are that very probably people with chronic depression die
young. So it looks as if we're probably looking at a very profound
multisystem disease that may even affect people who themselves don't show this
last step of the process, which is this greatly disabling ailment that
involves sense of emptiness and inadequacy.

GROSS: I don't know, Peter Kramer, but after hearing you talk about
depression and the effects of depression and stress on the body, I feel like I
need an anti-anxiety pill. It's just so worrisome, it's making me so nervous.

Prof. KRAMER: Well, maybe what you need is a quiet drive in your car and a
good listen to the radio.

GROSS: My guest is Peter Kramer, author of the best-seller "Listening to
Prozac." His new book is called "Against Depression." We'll talk more after
a break. This is FRESH AIR.

(Soundbite of music)

GROSS: (Technical difficulties) new book is called "Against Depression."

You know, there are different kinds of depression, and I think one theory is,
you know, that some depression is caused biologically, it's caused by things
happening in the brain chemistry or in the brain itself, and that other forms
of depression are just, you know, understandable responses to things that have
happened in your life. You know, the death of a loved one, the loss of a job.
And that these kinds of depressions might be fundamentally different.
The--you know, the depression caused by life events is the kind of depression
you might recover from whereas the kind of depression caused by brain
chemistry is something that might continue through your life. So do you feel
like you have a better understanding now about the difference between the two
kinds of depressions and the different ways that psychiatrists should be
treating them?

Prof. KRAMER: Well, researchers have struggled with this problem over
decades, and they have wanted to make the kind of distinction you're making,
and the data keeps getting in the way. Early on it was thought that if you
had a depression that was caused by genetics, that was a real depression, and
these sort of neurotic, operatic, flamboyant depressions of people who were
just sensitive and vulnerable were something else. But that distinction
turned out to be hard to maintain because the non-genetic depressions caused
just as much risk, there was as much likelihood of subsequent depressions, as
much risk of suicide, as much of these other things like heart disease as in
the so-called genetic depressions.

And the behavioral genetic studies in the end showed that a high biological
likelihood to depression puts you a few depressions down the road so that if
you come to depression through stress, you know, by your third depression
you're in fairly bad shape, whereas if you come to depression through very
high genetic loadings, your first depression may look like somebody else's
third depression. But from there on out, the process looks very similar. And
I think in the end there's some sort of prejudice or stigma involved in the
attempt to keep that distinction. After all, we don't say that an episode of
asthma is justified because a person is under stress or because a person has
run into a certain kind of allergen. And I do worry that this justification
is an attempt to set aside what we really do know about depression.

GROSS: And just to clarify again, when we're talking about depression, you're
not talking about sadness. What are you talking about?

Prof. KRAMER: I'm talking about whatever it is that we're talking about.
That is this thing that damages probably the hippocampus and the prefrontal
cortex, and depression is identified through a symptom checklist so that if
you are suicidal and guilt-ridden and you can't enjoy things and you're
tearful and you have trouble with sleep and appetite, you have a certain
intensity of those symptoms and certain numbers of them, certain choice among
them, you get this diagnosis of being in an episode of major depression, and
that's sort of the entry ticket, if you have enough episodes of major
depression, you have recurrent depression, so that is what we're talking
about.

And one could have depression without being very sad. In fact, throughout
history, you know, if you look at the history of melancholy over centuries and
millennia, sadness is not even necessarily the key factor in depression. It's
this emptiness, hollowness, paralysis of action, lack of energy. It's a very
clear, overwhelming condition.

GROSS: Your book, "Listening to Prozac," was published in 1993. Very
important book, a best-seller. Doctors have learned, scientists have learned
a lot about depression since then, but we're still using some of the same
medicines you wrote about in 1993 such as Prozac. Do you feel like now that
we know more about depression, are these medicines still as effective as you
once thought that they were?

Prof. KRAMER: I never thought that Prozac was particularly effective against
depression, and "Listening to Prozac" isn't mainly about depression. I think
one reason I wrote this book "Against Depression" is to enter that territory
and face depression head-on. "Listening to Prozac" was about the possibility
that we would have medications to affect fairly minor conditions and even to
alter personality, and I wrote in "Listening to Prozac" that Prozac was
probably less effective against major depression than some of the older
medicines that have less well-tolerated side effects. So, no, I think our
armamentarium is not as good as it should be.

That said, since depression looks more dangerous, we are probably justified in
using what interventions we have quite vigorously. And we're reasonably good
at treating depression. I mean, if you look at the data on any one drug,
usually these medicines have very marked effects in 50 percent to 60 percent
of people, but that's just one medication in a fairly sanitized trial where,
you know, doctors are limited in how they can prescribe the medicine. If you
would look at the overall effect of psychiatric intervention under the best
circumstances, you could give psychotherapy with medication, you could add a
second medicine or change medicines. I think, you know, our ability to
interrupt an episode of depression is fairly good and we're, in fact,
surprised and frustrated if we can't do that. For most patients we can.

GROSS: Do you think that there will be a new wave of antidepressants that
scientists create pretty soon that will be much more effective in dealing with
depression?

Prof. KRAMER: I think that sooner or later there'll be much more effective
medications. It's very hard to predict the time course of introductions of
medicines. You know, during the last 10 years there's been a lot of interest
in stress hormones and interrupting the attack of stress hormones on the
brain, and there are medicines that are quite capable of doing that, but they
have such marked side effects that it's not possible to give them to people.
And so the question is when one can develop a medicine that does what we like
medicines to do and yet, you know, have them be well tolerated.

Now if we get those medicines, it will--there will be interesting ethical and
moral conundrums about when to give them. For instance, if you could give a
medicine that would make it so that a child who lost his parents did not have
the brain affect of that loss, that is wasn't predisposed, say, you know if
one imagines that this is the case, to later episodes of depression or anxiety
disorders, would you give that medicine in that case? And is that different,
say, than a case of a very vulnerable person who loses a spouse and has to go
on in life? Is it different from cases of rape? So I think if we could break
the link between stressers and various kinds of mental effects, we'd be faced
with then, you know, when do we want to do that.

GROSS: Peter Kramer is the author of the new book "Against Depression." He's
a professor of clinical psychiatry at Brown University. He's also the host of
the public radio mental health program "The Infinite Mind." He'll be back in
the second half of the show.

I'm Terry Gross and this is FRESH AIR.

(Announcements)

GROSS: Coming up, creating a TV show that's a cross between a whodunit and a
medical drama. We meet David Shore, executive producer of the FOX TV series
"House," and actor David Foster, a medical consultant and writer. Also, more
on depression with Peter Kramer.

(Soundbite of music)

GROSS: This is FRESH AIR. I'm Terry Gross back with Peter Kramer, the author
of the 1993 best-seller "Listening to Prozac." His new book, "Against
Depression," argues that depression needs to be taken as seriously as any
other disease and treated with medication.

There's been a lot of concern lately, even, I believe, congressional
inquiries, into how antidepressants can make teen-agers suicidal. How do you
interpret the latest information on that?

Prof. KRAMER: I think it's for the good; that is, I think that those worries
will make doctors have more appointments with their patients. I think it
always was inappropriate, if this was going on, to give adolescents a medicine
and say, you know, `Come back in a month and we'll see how you're doing.' So
I think on a public health basis, that concern is good. That said, I always
have particular worries when it comes to depression; that people don't look at
the downside. That is, we're looking at medicines to have a certain degree of
risk attached to them and--at a disease that has a great deal of risk attached
to it. And on a public health basis, also, if you look where the medicines
have been introduced--there's been lots of public health studies.

You know, what happens when a country starts to license medicines like Prozac?
And whether it's in, you know, New Zealand or Scandinavian countries, certain
counties in the United States where these medicines become more used, you see
a decrease in suicides. And, in particular, you see a decrease in adolescent
suicide, and you see that even where other markers of sort of turmoil, like
public alcoholism and so on, don't go down. So it looks as if, on a public
health basis, these new antidepressants are among the very few things we know
of that actually decrease suicidality across the society. They do probably
better than things like suicide hotlines, you know, just taken as a simple
intervention.

But I do think that it's going to be very important for doctors to be very
careful with depressed patients, you know, given whatever intervention they
give. And, you know, very likely in the older-age groups, antidepressants are
going to be a part of that. The medicines are just less effective also with
children and adolescents, which is a separate problem.

GROSS: Now I want to go back to where we started, which is the fact that a
lot of people seem concerned that if we found a way to do away with
depression, we would also be wiping out something very important in our
culture, which is alienation, a level of introspection that seems very related
to artistic endeavors of every sort. And, basically, you're saying people are
very romantic about depression in a way that they are not romantic about other
diseases. And I'm wondering what you think it is about depression that
makes--that has created this kind of almost aura around it.

Prof. KRAMER: I compare it partly to tuberculosis. You know, if you have a
disease that has people wasting away slowly and that affects people of all
ages and all social classes, you develop romantic myths around it. And we've
had depression as part of the human capability for millennia, and, you know, I
think the result is complicated, one--both that there's some attraction in
attributing romance to this condition and that we just have too long a history
that it's embedded in our notion of what the self-aware person is. I think
"Hamlet" gets some of the blame; that there happened to be a great fashion in
melancholy in the Renaissance, and it happens that the signal iconic literary
figure of our culture is a deep melancholist.

And I wonder what a culture would look like that was very much less liable to
depression. I think the--you know, I've had to say that, you know, where my
novelist's mind was, as I was writing "Against Depression," where the sort of
creative originality is in this book, I think it's in thinking about this
question of whether maybe we do overvalue things like alienation and, you
know, we miss--I was challenged by a philosopher actually in writing about
whether we ought to give Prozac to Sisyphus, rolling his rock endlessly up the
hill. And I went back to the Camus essay, and, of course, Camus says that
Sisyphus was happy. We need to imagine Sisyphus happy; that there is joy in,
you know, knowing something about the absurdity of our condition or that our
awareness of absurdity comes from how joyous our lives are, even in the face
of the stresses that are placed on us. And I thought, `How could someone have
forgotten that?'

And the reason that people forget that Sisyphus is joyous is that we have
condensed this metaphor of depressive and deep and have started to believe
that depth is automatically related to depression. And I think that's not so.

GROSS: Have you ever seen Sisyphus as a metaphor for obsessive-compulsive
syndrome?

(Soundbite of laughter)

GROSS: He says the same thing over and over and over again, without it being,
you know, productive in the literal sense.

Prof. KRAMER: I see Sisyphus as an icon of freedom. I think that the notion
that we can retain our autonomous thought, even in the face of very terrible
punishments imposed on us, is really the saving grace about the human
condition in the modern world.

GROSS: Peter Kramer, thanks so much for talking with us.

Prof. KRAMER: Thank you.

GROSS: Peter Kramer is the author of the new book "Against Depression."

Coming up, creating the Fox TV medical series "House." This is FRESH AIR.

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Interview: David Shore and David Foster discuss their TV show,
"House"
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross.

Part medical drama, part mystery story, the Fox TV series "House" has become a
big hit, with the help of its Tuesday-night lead-in, "American Idol." My
guests are David Shore, the creator and executive producer of the series, and
David Foster, a physician who left his work at Beth Israel Deaconess Medical
Center in Boston to be a writer and medical consultant on "House."

"House" stars Hugh Laurie as a brilliant doctor, whose job is to consult on
the most mysterious cases at a teaching hospital in Princeton, New Jersey.
The doctors and patients at the hospital pay a price for Dr. House's medical
genius. They have to deal with his abrasive personality and condescending
manner. As a result of a leg injury, Dr. House walks with a cane and is
usually in pain, which only adds to his unpleasant disposition. Each episode
starts with someone getting very sick with a life-threatening problem that is
incorrectly diagnosed, until House steps in.

In this episode, a 12-year-old girl has had a seizure in the middle of a
swimming competition. The doctors assume it's part of a larger outbreak of
spinal meningitis. Here's Dr. House sharing his skepticism. The head doctor
is played by Lisa Edelstein.

(Soundbite of "House")

Mr. HUGH LAURIE: (As Gregory House) Twelve-year-old female, fever, rash,
neck pain. Not meningitis.

Ms. LISA EDELSTEIN: (As Lisa Cuddy) It's the definition of meningitis.

Mr. LAURIE: (As Gregory House) Sure. Puss in the spinal canal makes it hurt
to move your head up and down, but her neck only hurts moving side to side.

Ms. EDELSTEIN: (As Lisa Cuddy) Oh, side to side.

Mr. LAURIE: (As Gregory House) Doesn't fit.

Ms. EDELSTEIN: (As Lisa Cuddy) The three of you, lobby now.

Mr. LAURIE: (As Gregory House) Those little pills you're passing out so
efficiently aren't going to do Ms. Luganis(ph) squat.

Ms. EDELSTEIN: (As Lisa Cuddy) You just don't want to deal with the
epidemic.

Mr. LAURIE: (As Gregory House) That's right. I'm subjecting a 12-year-old
to a battery of dangerous and invasive tests to avoid being bored. OK, maybe
I would do that, but I'm not. Turns out she's got meningitis, you're right,
you win. But if we go back downstairs and she dies, your face will be so red.

Ms. EDELSTEIN: (As Lisa Cuddy) You have one hour.

Mr. LAURIE: (As Gregory House) If you have a lumbar puncture, some brain
infections can be pretty clever at hide-and-seek.

Unidentified Man #1: I'll get on this blood work.

Mr. LAURIE: (As Gregory House) No, you won't. You, sir, will research all
the causes in the universe of neck pain.

Unidentified Man #1: The list is, like, two miles long.

Mr. LAURIE: (As Gregory House) Start with the letter A, and put her on
rifampin.

Unidentified Man #1: Rifampin is for meningitis. You just said...

Mr. LAURIE: (As Gregory House) In case I'm wrong. It has happened.

GROSS: David Shore, Dr. David Foster, welcome to FRESH AIR.

David Shore, how did you describe the series when you were first pitching it?

Mr. DAVID SHORE (Creator, Executive Producer, "House"): It's a very
different series now than what we initially pitched. We came in with just the
basic procedural ...(unintelligible). The character of Dr. House was not
defined in any way, shape or form. It was--it much more closely resembled
"Law & Order" or that kind of show, except with germs as the suspects and
germs as the bad guys and investigating that news. It was pitched as a team
of doctors who try and diagnose the undiagnosable cases. And, to be honest,
it was a bit of a bait-and-switch that went on, not intentionally. But as we
were developing--so the networks went crazy for that. They thought it was
great. We actually had a couple networks bidding on it.

And it's a show--what I realized was when you're dealing with a procedural
police drama, you've got all these motives; you've got all these people hiding
things. Germs don't do that, obviously. You know, you don't have one germ
blaming another ge--framing another germ because he was sleeping with the
first germ's wife.

GROSS: (Laughs) That would make an interesting series.

(Soundbite of laughter)

Mr. SHORE: It would. If I could have done that, the show--that's what I
would have done. But we couldn't do--so we realized that--and it just makes
it better ultimately. We realized, `Well, you can't just have a dry
procedural in this environment. We have to make characters interesting.' And
I just started thinking about what sort of doctor would be interesting to
watch, and it evolved from there.

GROSS: Why'd you decide a doctor who's really unpleasant would be interesting
to watch? Doctor's really rude to everybody, very condescending.

Mr. SHORE: I did actually. That's exactly what I decided. It's--I just
think--from my personal dealings with doctors, I just find that most of what
they deal with is so mundane and so uninteresting that they--it's got to drive
them crazy. And, also, I think that most people would love their jobs a lot
more if they didn't have to deal with people.

(Soundbite of laughter)

Mr. SHORE: We all view ourselves...

GROSS: Not me. I wouldn't have a job if I wasn't a people person.

(Soundbite of laughter)

Mr. SHORE: Yeah, that's a good point. But there are other people--I'm sure.
We all view ourselves as being the brilliant people being surrounded by idiots
on a certain level. We also all view ourselves as being hopelessly
unqualified and fooling everybody. But I just thought it would be really
interesting to have a guy who just said those things and just wasn't afraid to
say those things.

GROSS: Now the show follows a formula. The patient comes in. They're going
to die within a few hours unless the doctors can diagnose the problem and fix
it. The first diagnosis is always wrong. Then House leads the doctors in a
discussion of what else they should be looking for. Let me play an example of
House leading the doctors in the discussion of what else they should be
looking for. So in this scene, you know, a patient has come in because of
seizures. She's a teen-aged girl who's just come back from a swimming
competition with the seizures. And the doctors have been assuming it's
meningitis, but House has been skeptical. And so this scene will give you a
sense about how he questions the other doctors and goes about making a
diagnosis. They're near a men's room, I should say. Is there anything you
want to add before we hear the scene?

Mr. SHORE: Well, they're actually in a men's room, which, if I can just add
something about that--one of the things I really love about this episode is
it's so not your--I think it's not your typical medical drama episode in the
sense that it's actually the opposite of it. We've got this meningitis
epidemic in the hospital, which obviously would normally be the story in, I
think, basically any other TV show about doctors. We decided to make it the
annoyance to House. There's this meningitis outbreak, and he's doing
everything he can to avoid being involved in that 'cause he's got one case of
one person who's sick that's interesting, whereas meningitis bores him. And
so they're doing the differential diagnoses in the men's room in this scene to
avoid being caught doing this work.

GROSS: OK, let's hear the scene.

(Soundbite of "House")

Mr. LAURIE: (As Gregory House) I'm sure it was an abcess seizure.

Unidentified Man #2: Absolutely. She was totally unresponsive and unaware of
what was going on around her.

(Soundbite of grunting)

Mr. LAURIE: (As Gregory House) Do you mind? We're trying to work.

Unidentified Man #3: We should get back out there. Cuddy's going to be
looking for us.

Mr. LAURIE: (As Gregory House) Looking but not finding. Did you do an EEG?

Unidentified Man #4: Seizure frequency's increasing. They're almost constant
now, five in the last half-hour.

Mr. LAURIE: (As Gregory House) Which tells us?

Unidentified Man #4: It's definitely in the brain.

Unidentified Man #5: And it's getting worse.

Mr. LAURIE: (As Gregory House) And?

(Soundbite of grunting)

Mr. LAURIE: (As Gregory House) Good Lord, are you having a bowel movement or
a baby?

Unidentified Man #6: Could be barbiturate withdrawal.

Unidentified Man #4: No, can't be drugs. She's tested at every meet she
competes at.

Mr. LAURIE: (As Gregory House) A bleed in the brain can cause seizures.

Unidentified Man #7: Blood poison.

Unidentified Man #8: Could also cause neck pain.

Unidentified Man #4: You think she's eating off the floor of her folks'
garage?

Mr. LAURIE: (As Gregory House) She doesn't have to be.

Unidentified Man #4: Who would poison a 12-year-old?

Mr. LAURIE: (As Gregory House) Well, let's see now. There's the 18-year-old
has-been that she beat out at the nationals; has-been's parents; jealous
siblings; sociopathic ...(unintelligible), and then there's just her plain ol'
garden-variety wack-job.

(Soundbite of toilet flushing; door slamming; footsteps)

Mr. LAURIE: (As Gregory House) Hey, you know what a hemorrhoid is?

Unidentified Teen: No.

Mr. LAURIE: (As Gregory House) Well, Google it. Try some raisin bran
instead of the doughnuts.

GROSS: That's a scene from "House." And my guests are David Shore, the
creator of the series, and Dr. David Foster, a doctor who has been writing
and consulting for the series.

So where do you get the rare diseases from? Where do you find them? To go
looking through rare medical books or through, you know, medical sections of
newspapers and magazines? You know, Dr. Foster, did you actually have cases
like any of the ones on "House"?

Dr. DAVID FOSTER ("House" Consultant): Some of the cases are from my
experiences and the experiences of some of the other doctors that we have
working on the show. Some come from medical journals. Some come from the
Internet, friends at parties, doctors who think we're always canvassing the
doctors that we know for what their most interesting case was or what their
most difficult problem that they had to solve was.

GROSS: So...

Mr. SHORE: And their most annoying patients as well.

Dr. FOSTER: Their most annoying.

GROSS: (Laughs) Well, my favorite diagnosis, there was an episode where--I
think it was, like, a teen-age boy who a few weeks ago was sick, and everybody
thought, `Oh, he's been poisoned, or he's been exposed to some kind of toxic.'
And it turned out, it was some--had to do with his exposure to termites in the
wall of his home that no one even knew were there; no one even knew the home
had termites. But Dr. House, figuring this out, actually goes--punches a
hole in the wall, finds the termites.

Mr. SHORE: Only after spitting on a surgeon to stop a surgery midprocess.

Dr. FOSTER: And autopsying the cat to find the termite in the cat's belly.
The cats had died.

GROSS: (Laughs) So who came up with this termite-related--I hope
rare--illness?

Dr. FOSTER: That actually came out of a conversation between myself and one
of the writers and a consultant from the CDC. We were actually calling about
a different story, and the person said, `You know, this is something that I
find interesting. This is an interesting story to me.' And we took it and
ran with it.

GROSS: OK. So you figure out that the termites are going to cause this
illness, but, of course, you have to misdiagnose it during the first scene.
So had it--then you have to figure out how to rediagnose it in a convincing
way.

Mr. SHORE: Well, this is one of the ways that the--to try and keep this
interesting and not just have it be purely medical. We try and keep the
personal aspects of it alive, and therefore quite often the misdiagnose comes
from either an intentional or an unintentional lie from the patient or the
patient's family.

GROSS: Now not only is House, like, a brilliant doctor and detective, you
know, the Perry Mason of medicine, but he does everything himself. You know,
he's given one woman a gynecological internal exam. He's done a pelvic
ultrasound for another. You know, doctors never do ultrasounds. There's
technicians who do ultrasounds (laughs). So, like, Dr. Foster, do you ever
step in here and say, `Wait a minute. No one's going to buy this'? Like, Dr.
House isn't going to be doing these particular procedures.

Dr. FOSTER: Well, there's a line between `usually does' and `could.' I
mean...

Mr. SHORE: Yes, he does. And I tell him he's going to do it anyway.

GROSS: Well, why is he going to do it anyway?

(Soundbite of laughter)

Mr. SHORE: Because it's more interesting to watch Dr. House do it than to
watch some doctor we've never seen before do it. And, quite--and, again, I go
back to the conceit of the show. And I may--this may be somewhat of a
rationalization, but I--we've created a character here who doesn't trust
anybody. And so I--to a certain extent, we can get away with pushing the
boundaries a little bit because he is so off the wall, and he doesn't trust
other doctors. So his reaction's going to be, `You do it, not somebody else.'
He wouldn't necessarily personally do it, but his team would do it.

GROSS: Now, you know, we've talked about what a toxic personality he is and
what a bad bedside manner he has. And you've mentioned that, you know, a lot
of the stories--a lot of the misdiagnoses is based on lies that the patients
or their families tell. Now in the episode that we've heard clips from, this
student who has been in a swimming competition has had seizures; everybody's
convinced it's part of this meningitis outbreak, except Dr. House. He thinks
it's something else. And he finds out it is something else, and this
something else is also related to the fact that she is pregnant and she hasn't
told anybody, and she certainly hasn't told her parents.

So when he solves the problem and he realizes he's also going to have to
perform an abortion to save her life, he can't tell the parents because she
doesn't want the parents to know, and he doesn't have the right to disclose it
if she doesn't want them to know. So I want to play a scene where he's
actually trying to describe the diagnosis and the procedure to the parents
without actually having to tell them that she's pregnant. Here's the scene.

(Soundbite of "House")

Mr. LAURIE: (As Gregory House) Your daughter has TTP. Don't worry, it's
curable. She'll be fine.

Unidentified Woman: Well, wait. I mean, what does TTP stand for?

Mr. LAURIE: (As Gregory House) Some really big words that you'd never heard
before and when we're done we'll never hear again. Have a nice day.

Unidentified Man #9: Well, when can we take her home?

Mr. LAURIE: (As Gregory House) In a few days. She needs some minor surgery
to remove the underlying cause before we can do the--another really big word.

Unidentified Man #9: What's the underlying cause?

Mr. LAURIE: (As Gregory House) She has an abnormal growth in her abdomen.

Unidentified Woman: What kind of surgery?

Mr. LAURIE: (As Gregory House) It's very simple. Do it here all the time.

Unidentified Man #9: Could you be a little more specific?

Mr. LAURIE: (As Gregory House) Actually, no. I'm sorry.

GROSS: Hugh Laurie, determined Dr. House, in a scene from "House." My guests
are the creator, David Shore, and Dr. David Foster, who is a consultant and
writer for the series.

Can you talk a little bit about how the condescending, rude, insulting lines
are written for Dr. House?

Mr. SHORE: That's the greatest thing about writing for this show, I
think--is writing for Hugh Laurie in particular--writing for this character
and writing for Hugh Laurie 'cause he pulls off these amazing things, and he
can take these incredibly dramatic, incredibly serious scenes and you can
write a joke in the middle of it and he pulls it off. And it doesn't lose any
of its import, and it becomes funny without becoming silly. And what we tend
to do when specifically writing the scenes is we write the scenes dramatically
first and then rewrite them to bring in the attitude 'cause the one thing I
want to stay away from--we never want to make him nice, but we also don't want
him to be nasty.

I think the reason people are responding to him is because he's never nasty
just for the sake of being nasty. He's clearly nasty, but there's always some
reason for why he's doing it. It's always something he's trying to
accomplish, whether it's as simple as learning something about the patient or
learning something about the condition, but there's always a reason--or
getting them to change their behavior. There's always a reason. And,
frankly, if we were to go with our guts, we would just write joke, joke, joke,
joke, joke, funny, funny, funny, nasty, nasty, nasty. We've got to start with
where he's going and what he's trying to achieve and work backwards from that.

GROSS: My guests are David Shore, the creator of the TV series "House," and
Dr. David Foster, a medical consultant and writer on the show. More after a
break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guests are David Shore, the creator of the Fox medical series
"House," and Dr. David Foster, a medical consultant and writer on the show.

You know, in a lot of procedurals, the program basically follows a formula,
and you can set your watch by it. Like, in "Law & Order" shows, you could
basically know exactly what time the police are going to be done with the
story and, you know, the DA's going to come in or the prosecutor's going to
come in. And, like, in "House," you could basically set your watch by what
time, you know, the patient's going to be brought in, when they're going to be
misdiagnosed, when the first breakthrough's going to be in the actual correct
diagnosis and so on. What are the advantages of writing a series that follows
a formula?

Mr. SHORE: There's something somewhat comforting about it. As long--the
challenge is keeping it--you know, the disadvantages are obvious. I mean,
when you describe it that way, it sounds terrible. But it--I can't argue with
it too much. We try and mix it up every now and again. We did one a few
weeks ago where, at the end of--by the end of Act II, we knew exactly what was
wrong with the person. It was just a question of what's going to happen to
them. So we do try and mix it up. But it is the nature of story-telling; it
just becomes more obvious in a situation like this--that you have a formula
going on. But it is comforting. The audience likes to play along. It's a
game. It's the audience playing along with the game. The game happens to be
exactly 44 minutes long or whatever it is--an hour with commercials. But it
is something that people feel used to and comfortable with. And if they like
the way it's being told, I think they're going to continue to like it, as long
as it continues to be smart and continues to--you don't know why--you know
something's going to go wrong, but you don't know what's going to go wrong.

GROSS: I think one of the things that both crime shows and medical shows are
doing is pushing the kind of language and descriptions of the body that you're
likely to hear on television. Let's face it, you know, "Law &
Order"--SVU--"Special Victims Unit," and just about everybody on a show is,
like, a rape victim. There's often some pretty explicit descriptions of the
evidence. And, you know, on "House," there's been some pretty explicit
descriptions, too. Do you find that interesting, the way crime shows and
medical shows are--seem to be pushing the boundaries a little bit of
prime-time broadcast television?

Mr. SHORE: I do. It's interesting. I mean, in terms of--I think it's very
true that that's happening. And I think, to some extent, it's just keeping up
with the special effects you see on TV, which we use to some extent and a lot
of other shows are using; that if you graphically show something, it's very
difficult to not graphically describe it. And I just--I also think it's just
a natural progression of the audiences becoming savvier and savvier and
dealing with the realities of the situation. To water down a description, you
just lose something. You lose something very major when you water down a
description. And if the show's at all dealing with the fundamentals of
it--but I--in--practically, for our show, it's actually very tricky because
we've created this character whose bread and butter is, in a sense, saying the
unsayable. And that is the exact opposite of what network instincts are.
Network instincts are to not shock people, and...

GROSS: Especially right now (laughs).

Mr. SHORE: Yeah. Yes, very true. And...

GROSS: Yeah. So who do you have to pass the dialogue through now before it
can get on the air when House is saying the unsayable or when describing
something explicit with the body?

Mr. SHORE: Yeah, they have a Standards and Practices Department at Fox to
deal for--obviously, certain obscenities are--well, all obscenities are
verboten. And it's more dealing with--like in the episode you showed--you
played some clips from, there was a rather graphic line where he is trying to
convince her to talk to her parents, and he's very, very strong about it. And
I think the line was something along the line--if I can say it, it was,
`You're old enough to bleed out of your vagina. Now old enough means you're
old enough to make your own decision.' And he's--or, pardon me, `old enough
to do whatever you want.' And he's obviously trying to make a point to her to
say, `You're a 12-year-old kid; you've got a lot of growing up to do.' If he
were to hold her hand and say, `You're a 12-year-old kid; you've got some
growing up to do,' it wouldn't have the same impact. And it was an issue.
The very issue of having a 12-year-old pregnant girl on TV was a real issue,
and, you know, you've got to choose which battles you fight, and we won that
battle.

GROSS: What did you say to win it?

Mr. SHORE: We said exactly what we just described here, which is that that's
the whole point of this episode. The whole point of this character and the
whole point of this episode is this kid is a kid. We are not endorsing that
sort of activity, but 12-year-olds are doing the exact opposite. We are
actually talking about how a 12-year-old is a 12-year-old; a 12-year-old is a
child. And that is what makes it--that is exactly what they're objecting
to--is the shocking nature of it. But the shocking nature of it comes from
the fact that she is a child, and she is experiencing these adult experiences
before she's ready to experience them.

GROSS: David Shore, Dr. David Foster, thank you both so much.

Dr. FOSTER: Thank you.

Mr. SHORE: Thank you, Terry.

GROSS: David Shore is the creator and executive producer of "House." Dr.
David Foster is a medical consultant and writer on the show. The season's
finale is next Tuesday night.

(Soundbite of music)

(Credits)

GROSS: I'm Terry Gross.
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

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