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 21^st 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.

Categories: Philosophical, Medications, Ethics