Review - Medicating Modern America
Prescription Drugs in History
by Andrea Tone and Elizabeth Watkins (Editors)
NYU Press, 2007
Review by Benjamin J. Lovett, Ph.D.
Dec 4th 2007 (Volume 11, Issue 49)

It is no longer news that America is psychologically dependent on drugs, and legal drugs--prescription drugs--in particular. In the past decade, a considerable number of books and articles have come out attesting to Americans' interest in using medications to soothe the pains of everyday living and to enhance their lives in ways ranging from personality change (Prozac) to height increases (synthetic human growth hormone). However, most of the extant literature on the topic has dealt with psychological functioning and the drugs designed to affect it. Even Viagra, a favorite case study in the interface between medicine and society, falls under psychological functioning, since "male erectile disorder" is technically considered a mental disorder, according to the American Psychiatric Association. Medicating Modern America expands the boundaries of this inquiry to encompass a more diverse selection of drugs, including antibiotics, oral contraceptives, and even drugs for controlling cholesterol. The contributors, mostly historians, provide narrative accounts of how eight different drug classes became part of American life, and how they helped to redefine the conditions that they were used to treat.

In the editors' introductory essay, Andrea Tone and Elizabeth Watkins provide a general context for the issues under study here. They remind us, for instance, that the very idea of a prescription drug is a recent one. With the exception of a few select agents (e.g., narcotics), drugs were generally available without a prescription in the United States until 1951, when the Food, Drug, and Cosmetic Act was amended to require that, before obtaining a medication, patients consult with a physician and get evidence of a recommendation to take the medication. If that amendment demonstrated recognition of the potential dangers of medications, the recognition was only a corollary to the enormous appreciation for the benefits of medication for society, an appreciation stimulated by the orally ingested penicillin that had been introduced less than a decade earlier, and that was credited with saving many lives. This two-sided conception of drugs--as having immense power for good, but also potential for substantial harm--is seen in several of the drug histories in Medicating Modern America, and serves as a general theme to unify what are otherwise very different stories.

This theme is especially evident in the first chapter of the book, where Robert Bud chronicles the rise and fall of antibiotics, initially hailed as "wonder drugs," and then blamed for their role in increasing bacteria strains' resistance to treatment. Bud points out that with antibiotics, pain from even minor and self-limiting maladies such as earaches was unnecessary pain, and so the drugs became more widely prescribed, further increasing the potential for bacterial resistance. He also notes the complex effects of antibiotics on the sociological nature on doctor-patient interaction. Specifically, antibiotics led to a more technical conception of the role of medicine, in which the duties of patients were reduced to seeking medication, and the role of doctors was limited to providing a prescription. Even the fact that the drugs were so effective altered the patient-provider relationship, since the physician no longer had to wait out the infection with patients, preparing them and their families for the worst, and helping family members through grief after a patient succumbed to infection.

A second theme emphasized throughout the book is the nonspecific nature of drugs as treatment agents--that is, how they are often developed for one problem, marketed as treating other problems, and used by doctors for still other problems. Perhaps the most extreme example of this is seen in the history of psychostimulant drugs, chronicled in a chapter by Ilina Singh. Although these drugs are today associated most with attention deficit hyperactivity disorder (ADHD), in past decades, they were touted as having utility for patients with a variety of problems, and the most famous drug in this class, Ritalin, was initially marketed as a treatment for narcolepsy. Patients with fatigue (especially elderly patients) were another class that was seen early on as a target patient group for the stimulants. But when the term "minimal brain dysfunction" (MBD) was coined to describe children with hyperactivity problems, the maker of Ritalin (Ciba) saw a niche market, and stimulants became the preferred treatment for MBD, a tradition that has continued in MBD's descendents, ADD and ADHD.

A third theme seen in several chapters involves the ways in which the threshold for diagnosis of a disorder shifts once an effective treatment (here, a medication) is available. The case study of statin drugs by Jeremy Greene provides a careful analysis of this phenomenon. Initially, the only type of high cholesterol level seen as pathological was "xanthomatosis," a congenital disorder in which cholesterol levels were so high that fatty tumors formed in body tissues where cholesterol was deposited. By the 1960s, the distribution of cholesterol levels in the population was used to determine what constituted "abnormally high" levels--specifically, levels in the top 5% of the population were considered to be too high. Using statistical deviance as a marker of pathology had certain limitations, but at least it kept overdiagnosis at bay. Then, in 1985, associations between cholesterol levels and heart disease across different countries led the National Institutes of Health to conclude that the statistical approach to abnormality had led to underdiagnosis, and to claim that "a large fraction of our population probably has too high a blood cholesterol level." Greene tracks how our increased sense at being able to control cholesterol led to lowered thresholds, and he points out how the widespread use of statin drugs has pushed down those thresholds even further.

Medicating Modern America, then, provides a unique collection of drug histories--not histories of the ways that the drugs were developed, but histories of the drugs' places in society. The authors offer detailed chronological accounts, often with photographs of advertisements for the medications or other illustrations. In sum, the book is a set of fascinating case studies in the ways in which certain chemicals change how we view our own bodies, and anyone who has taken prescription medications can benefit by reading it.

© 2007 Benjamin J. Lovett

Benjamin J. Lovett, Ph.D., is an assistant professor of psychology at Elmira College, where he teaches classes on a variety of topics in applied psychology and his research focuses on the conceptual and psychometric foundations of psychoeducational assessment and psychiatric diagnosis.