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The Creation of PsychopharmacologyReview - The Creation of Psychopharmacology
by David Healy
Harvard University Press, 2002
Review by Rachel Cooper
Nov 8th 2002 (Volume 6, Issue 45)

The fundamental claim of The Creation of Psychopharmacology is that psychoactive drugs are a powerful force in history. Agents such as chlorpromazine, imipramine and Ritalin have altered our conception of what it is to be human to the extent that at the beginning of the 21st century we think of ourselves in biomedical terms. Earlier generations of parents worried about "sparing the rod and spoiling the child"; today they worry about their child's prescriptions. In the 1950s depression seemed rare; today some surveys suggest that up to one-in-four people suffer from depressive symptoms and, it is implied, could benefit from treatment with antidepressants. Increasingly, our problems are seen as being rooted in neurotransmitters, and our solutions come in pills.

Healy seeks to tell the story of how we came to think in this way. He charts the rise in the importance of psychoactive drugs from the discovery of chlorpromazine in 1952 to the present day. A key theme of the book is that the use and conceptualisation of drug treatments in psychiatry has been powerfully shaped by the marketing practices of pharmaceutical companies and by the demands of legislation.

The US is the biggest market for pharmaceuticals in the world; thus getting drugs licensed for use in the US is a priority for companies. Healy claims that the 1962 amendments to the US Food and Drugs Act put a premium on producing specific treatments for specific diseases. Rather than being able to develop treatments for "general nervousness", companies were forced to market drugs as being for the treatment of disorders such as schizophrenia, panic disorder, or obsessive compulsive disorder. The FDA also endorses Randomised Clinical Trials (i.e. trials in which patients are randomised to one of two drugs, and then the effects of the drugs are compared). Such trials require the use of standardised diagnostic criteria to select homogeneous subject populations, and standardised rating scales to quantify treatment effects. Healy claims that the requirements of the FDA have encouraged psychiatry to think in terms of specific disorders and to become obsessed with rating scales.

Some may think that the resultant "evidence-based" medicine is no bad thing, but Healy shows that the evidence is increasingly produced and managed by pharmaceutical companies. Pharmaceutical companies fund practically all research into psychiatric treatments, and they only fund work in their interests. The drugs companies are only interested in treatments that will make them money. Thus old and unpatentable therapies, though effective, come to be neglected, while new and expensive treatments are pushed, even if they work less well.

Healy claims that the FDA requirements, designed to protect patients, perversely make it easier for drugs companies to push ineffective drugs. Randomised Clinical Trials can be used to unearth the slightest treatment effect. They enable drugs to be marketed as "being effective" for depression even when they do so little that their effects might be unnoticed by an individual physician or patient. The use of strict diagnostic criteria in selecting subject populations can be manipulated by drugs companies, who can lump disorders together or split them, as best serves their interests. In his earlier book The Antidepressant Era (1997), Healy discussed how pressures stemming from pharmaceutical companies had resulted in anxiety-depression being split into a host of niche diagnoses – atypical depression, obsessive-compulsive disorder, panic disorder, and so on. This created niche markets for which antidepressants could be sold. In The Creation of Psychopharmacology Healy discusses a case where the opposite has happened. Catatonia, he claims, is a distinct disorder from other types of schizophrenia, and furthermore it is a disorder for which there are cheap and effective treatments. However, as these treatments are old and unpatentable, the interests of pharmaceutical companies are best served by lumping catatonia with other types of schizophrenia. Drugs companies sell more antipsychotics as a result, but patients suffering from catatonia are being denied effective treatments.

To sum up Healy's thesis: Psychoactive drugs are powerful. They have changed the ways in which we think of ourselves. They affect many of us more directly – curing our ills, or troubling us with side-effects. However, it was not inevitable that once these drugs had been developed we would come to use them and think about them in the way that we do today. The development of psychoactive drugs has been moulded by contingent factors - the requirements of legislation and the demands of the drugs market. These factors could have acted differently. If they had, our world would have been different, and in some respects better.

Healy's claims are important and controversial, but in some cases they are insufficiently supported by the evidence he offers. Take the effects of the FDA requirements, for example. Healy claims that the 1962 amendments forced drugs companies to market drugs for specific disorders - even in cases where they might be better thought of as "tonics" acting on generalised ills. It is hard to know what to make of this claim. Many medicines are for indications other than specific diseases – consider painkillers, diuretics, and so on. Surely the FDA can't be against all these? In addition, I found a 1970s article by employees of the FDA. which mentions that drugs were being produced for indications such as "the amelioration of morbid anxiety, elevation of depressed spirits, restoration of natural sleeping cycle, alleviation of pains, aches and discomfort, relief of fatigue, facilitation of the capacity to bear stress".[1] The authors claim that the FDA is needed to ensure that such drugs are as safe and effective as their manufacturers claim, but there is no suggestion that there is anything suspect about the indications for which the drugs are being developed. This at least places a question mark over Healy's claim that the FDA requires treatments to be for specific disorders. As such, it is unfortunate that he offers no evidence to back up what he says. Nor is this a lone example. Healy makes controversial claims throughout the book, almost in passing: "mortality rates for schizophrenia rise" (p.321), studies sponsored by pharmaceutical companies may be ghost-written and the subjects may not exist (p.310). References to studies that are supposed to back up these claims are given in notes, but when the claims made are surprising and controversial, it would be useful if supporting evidence were discussed in the main text. This being said, it is only a minor criticism of what remains an important and scholarly work.

The Creation of Psychopharmacology is a long book (over 400 pages) and is densely filled with facts. The key actors in Healy's story are psychoactive drugs, and those unfamiliar with their names may find it hard to follow the plot. However, anyone who is interested in how drugs have shaped society, and knows their imipramine from their Prozac, will benefit from Healy's book. His theses are important, and his book will remain a classic in this field for years to come.

 

© 2002 Rachel Cooper

Rachel Cooper is a lecturer in philosophy in the Department of Interdisciplinary Human Studies, Bradford University, U.K.

Link: Review of David Healy's The Antidepressant Era by Jonathan M. Metzl.


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