- The Washington Times - Sunday, March 17, 2002

By David Healy
Harvard University Press, $39.95, 469 pages

In Peter Carey's novel "Bliss," the mental hospital administrator Alice Dalton is desribed as "A woman with a mission, which was to demystify the treatment of mental illness. It was her experience that a lot of sentimental garbage was spoken on the subject … until she realized that Mental Illness was a business just like anything else. As for the treatment itself, her greatest axiom was derived from a psychiatrist who had explained it this way: the ones that are going to get better, get better; all the rest is psychiatrists being neurotic or self-important or anxious or guilty; effectively they cost a lot and achieve nothing."
I thought of Mr. Carey's character while reading David Healy's. "The Creation of Psychopharmacology." One of the founding historians of psychopharmacology (the use of medication in the treatment of mental illness, Mr. Healy prefers speaking of a "mental health industry rather than a mental illness service." And, like Alice, he doesn't think much of psychiatrists who, he believes, have sold out to pharmaceutical companies. "The market-development efforts of pharmaceutical corporations drive the psychiatric agenda far more than most people realize."
Mr. Healy is at best ambivalent about the overall effects of the psychopharmacological revolution in psychiatry, which started in the 1950s with the development of the anti-psychotic drug Thorazine. While he considers that many of the medications "stand among the greatest triumphs in modern medicine," he's also worried that the theories surrounding the new drugs are reaching out into the popular culture and shaping "the ways in which we see ourselves."
For example with the discovery of receptors (the molecules that provide attachment sites for drugs and thereby enable them to exert their effects) "the receptor vision quickly developed beyond a theory about how some drugs might work into a philosophy of all how all therapies should work." Soon psychiatrists and patients alike began speaking in a "newly minted biobabble" that gradually replaced the earlier psychobabble.
Patients, doctors and pharmaceutical companies now speak of "neurotransmitter imbalances" rather than emotional deprivations and traumas. This change in orientation is largely to the good; psychobabble engendered approaches to the mentally ill that were often unproductive and sometimes actually harmful. Nevertheless, expressions based on the new orientation can sometimes seem bizarre. Thus it's not uncommon now for patients to come to a psychiatrist requesting help in "increasing my serotonin levels" rather than for explanations for their difficulties couched in traditional psychological terms.
As an additional example of alienation the "medico-pharmaceutical complex" has gradually shifted its emphasis from discovering treatments for major diseases to medicalizing aspects of the human condition. As one of the results of this "medicalization" we now experience ourselves, Mr. Healy believes, in ways that are radically different from the ways which others experienced themselves before us. For example, "where once fear of God was a good thing that helped maintain the social order, fear has been replaced by anxiety and that anxiety is seen as a bad thing something to be treated."
Mr. Healy suggests that further developments in psychopharmacology are likely to follow the trajectory of cosmetic surgery (as suggested earlier by Peter Kramer in "Listening to Prozac"). And this shift from the mentally ill to the worried well will require that patients be able to obtain the agents on their own. "The idea that these agents should be available only by prescription is difficult to defend."
Mr. Healy's background as a historian rather than physician no doubt at least partially explains his failure to appreciate the serious consequences that can ensue when potentially harmful drugs are available without prescription. Nor does he see any inconsistency between suggesting that psychotropic agents be available over the counter and his claim that "some of these agents my trigger as many suicides as they prevent."
Rather than think through the implications of a "redesignation" of psychotropics as over-the-counter medicines, Mr. Healy takes a faux libertarian view: "Why should a physician with no ethical training have the ability to decide whether taking a pill that makes me less sensitive to work-related stress is a good idea?" Fair enough. But why should a historian with no medical training decide that drugs, which clearly have serious even fatal potential side effects, might safely be taken without some type of medical supervision?
While Mr. Healy presents an excellent overview of the history of psychopharmacology he loses this reviewer's confidence as a result of some quirky suggestions. For instance he favors the use of hallucinogens not as a means of elucidating brain function but to "provide insights into the influence of both visions and biology on religious thinking and on the possible interface between having visions and being moral."
At another point in the book he suggests that the increased incidence of eating disorders can be usefully correlated with the introduction after World War II of small portable weighing scales. "The growth in the weighing scale industry in fact parallels the growth in the frequency of anorexia nervosa." Perhaps so. But what conclusion are we to draw from this correlation? And should we grant it greater credence than other correlations that ocurred within the same time frame such as the burgeoning of the fast food industry, or movie and television glorifications of "thinness"?
Ironically some of the best parts of this book deal with aspects of psychiatry that have nothing to do with psychopharmacology. For instance Mr. Healy is rightly concerned with the "profound cultural shift" whereby psychiatrists (willingly or unwillingly) take on the role of gurus qualified to advise on "problems in living" that have little or nothing to do with mental illness but, rather, at controlling new and different forms of unacceptable behavior. Aggression and violence, for instance, are increasingly redefined as psychiatric rather than legal problems.
And Mr. Healy scores some telling points when he discusses changes in psychiatric practice, especially managed care. "Managed care organizations have placed increasing emphasis on offering quality services. But this emphaiss refers to the interest these organizations have in constraining clinicians … and forcing them to produce reproducible outcomes where risks are controlled. It does not refer to any interest in producing the best possible encounter between two human beings." In practical terms, this involves refusals by third-party health insurers to pay for therapies that cannot be conceptualized in psychopharmacological terms.
Overall, this book is a good place to start if you want to get an overview of the role of drugs in the treatment of mental illness. While Mr. Healy is partisan and highly critical of psychiatry and especially the pharmaceutical industry, he does capture an important current dilemma: "We live in an era when it has become possible not only to treat diseases but to enhance human potential, yet the divide between therapy and human engineering has not been the subject of sufficient debate."

Richard Restak, a neurologist and neuropsychiatrist, is the author of a dozen books on the brain and behavior. His latest book, "The Secret Life of the Brain," is the companion volume to a PBS television series.

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