Book of the Month: The Creation of Psychopharmacology
Authors: Allan Beveridge
Journal: Journal of the Royal Society of Medicine (2002)

David Healy's latest book1 is a hugely ambitious work which stretches from the time of the Enlightenment to the brave new biomedical world of the future. En route, it considers the emergence of asylum psychiatry, the rise and fall of psychoanalysis, the counter-culture's flirtation with hallucinogenics, the growth of the pharmaceutical companies, and the implications for mankind of the Human Genome Project. It is difficult to think of another psychiatrist who could have attempted such a grand narrative; even amongst historians, there has been a tendency to avoid such projects in preference to the small scale. An exception is the work of the late Roy Porter, with whom Healy bears some comparison. Both have combined erudition with accessibility to produce wide-ranging overviews of madness and its place in culture. Healy is well-placed to write such an ambitious book. He has an extensive knowledge, both of the historical literature and of psychopharmacology. He has also spent several years interviewing all the key figures in psychopharmacology, an enterprise which resulted in the three volumes of The Psychopharmacologists.

Healy's book is brimming with ideas. At the core is the seemingly prosaic tale of the emergence of the first antipsychotic drug, chlorpromazine. However, Healy invests this tale with great significance. He claims that the discovery of chlorpromazine was as important as the discovery of penicillin, and that its impact on society and the way we conceive of ourselves has been immense. We can discern at least three major themes in the book—first, the internal story of the discovery of chlorpromazine; second, the marketing of psychiatric drugs; and last, what developments in biomedicine tell us about ourselves.

The initial theme of the discovery of chlorpromazine proves to be a stirring story. Healy conveys the excitement of the early researchers in France as they administered the drug to their patients. Inmates awoke, Rip van Winkle-like, from the slumbers of their psychosis, and for many the world had changed completely. In the wake of the patients' return home, psychiatrists were obliged to venture outside the walls of the asylum. Thus, writes Healy, was community psychiatry born. He concedes that there is evidence to suggest that the asylums were emptying before the advent of chlorpromazine and that social factors played a part. However, he professes to find the argument as to why the asylums closed to be of secondary importance to the wider cultural ripples that chlorpromazine produced. The culture of psychiatry changed dramatically, most notably in America where psychoanalysis had ruled pre-eminent. Chlorpromazine was originally introduced to the United States by European emigres who worked in the unglamorous back wards of public asylums. The new medication was rapidly judged to be more effective than psychotherapy, and its triumph heralded the dawn of biological psychiatry. The creation of DSM-III in the 1980s underlined psychiatry's commitment to the biomedical model.

The advent of chlorpromazine marked the first occasion on which a psychiatric drug would be profitable. Indeed this is an understatement: chlorpromazine proved highly profitable. Healy describes the complex growth of the drug companies with great subtlety. Before the 1950s the manufacture of psychiatric medication was not considered financially rewarding. Since then, the market has exploded and millions of prescriptions for psychotropic drugs are issued each year. Is this because we are now recognizing illness that would have gone undetected in the past? Are we becoming madder? Or, as Healy suggests, have the drug companies successfully persuaded society that it needs pills. He notes that the incidence of depression seems to have increased a thousand-fold in the last few decades. Is this a fact of clinical epidemiology or have the drug companies created the demand? Healy also notices that different prescribing practices obtain in the West and the East. In the East they still prescribe benzodiazepines and rarely use antidepressants. Healy asks, mischievously: is the West leading the way to some biomedical truth or is this an example of the West's own culture-bound syndrome?

Marketing determines culture: this is one of Healy's major contentions. It is the market rather than the intrinsic efficacy of the medication that drives developments. Healy argues that there is no convincing evidence that the SSRIs (selective serotonin reuptake inhibitors) help the more severe cases of depression, but drug companies have been successful in creating a huge demand for them. Further, drug companies create markets for their products, rather than creating drugs in response to the needs of patients. For example, shyness was renamed ‘social phobia’, and, by happy coincidence a remedy was available in the shape of an SSRI. More than ever before, the drug companies control the data on pharmacological research, and negative results may be hidden. A recent and disturbing trend is the employment by drug companies of supposedly independent academics. Their names are then used to lend a spurious air of scientific neutrality to research papers and conferences. The boundary between an impartial scientific community and the profit-led pharmaceutical corporations is becoming blurred. With the budgets of the drug companies dwarfing those of research departments, these trends look set to continue.

Healy asks what these developments tell us about the history of science. Does scientific knowledge grow incrementally in response to ever more finely designed experiments? Or do new data leave theorists scrambling to accommodate them in ad hoc fashion? Healy concludes that the latter model is more applicable to psychopharmacology. Indeed he argues we are becoming less rather than more rational in our development of new treatments. Fashion plays a great part. Healy recounts the overlooked history of lithium. The popular perception is that lithium first appeared in 1949, but Healy reveals that it was actually in use in the 1880s and prescribed for mood disorders. However, the therapeutic rationale for its prescription was the uric acid hypothesis. When this hypothesis became discredited lithium fell out of favour despite evidence that it was effective.

Healy places his account of the development of psychotropic drugs within a grand narrative of the philosophy of man. The story of the discovery of chlorpromazine, he argues, can be traced back to the Enlightenment. It is a story that has profound implications for the ways we see ourselves. The philosophical underpinnings of Healy's book are the most interesting but also the most contentious part. He writes: ‘This is a story about the final death of vitalism, the notion that there is something special about human biology, something added by God or aliens perhaps’. But, to paraphrase Mark Twain, the reports of its death have been greatly exaggerated. Many thinkers do not accept that advances in the biological sciences have finally proved that human beings are nothing more than matter. The most recent voice to protest against this notion is that of Francis Fukuyama in his book, Our Posthuman Future, which argues that there is a indefinable ‘Factor X’ about human beings which is evident across cultures and historical periods2. Likewise Kenan Malik, in Man, Beast and Zombie,3 has stressed the ‘exceptionalism’ of man. In fact, since the Enlightenment there have been many voices that contested materialist views of humanity. As Richard Smith4 has shown, in his history of the human sciences, thinkers such as Dilthey, Bretano and Husserl have argued that the methods of the natural sciences are inappropriate to the study of man. In The Varieties of Religious Experience5, William James mocked the ‘medical materialists’ of his day for their attempts to explain away the spiritual aspect of humanity, while RD Laing, in the twentieth century, argued passionately that the ‘objective’ medical gaze could not deal with the patient's inner world.

Healy gives little room to these dissenting views about the nature of man. Instead he sketches an account of what he calls the birth of the ‘biomedical self’. It was, he writes, conceived during the Enlightenment when God was being dethroned and La Mettrie was proposing that man was a machine. At the end of the nineteenth century, psychoanalysis further undermined traditional views of the self. The 1960s, which witnessed great social upheavals and the counterculture's experiment with psychedelic drugs, produced a ‘break in how we understand ourselves as great as the changes of psychoanalysis’. The DSM-III of the 1980s took us further down the road to the biomedical self. Healy holds that our experience is radically different from that of our predecessors and, as a consequence, we are radically different people from those who came before. We can read a novel from the past but we are deluding ourselves if we think we can really understand the world of its characters. Is this true? Again there are dissenting views. Harold Bloom, the distinguished literary critic, maintains that Shakespeare's portrayal of human nature still resonates with us today. We continue to read his plays because we can identify with the individual characters. Bloom presents a strong case for the continuity of the self over several hundred years, rather than the radical breaks that Healy envisages6. Looking to the future, Healy concludes: ‘To believe that we will remain the same is unrealistic. We will change the biological basis of ourselves and our societies’. Whether we agree with this or not, The Creation of Psychopharmacology is one of the most original and thought-provoking commentaries on culture and psychiatry to appear for many years.