David Healy (1)

This is a massive book which straddles an uneasy line between scholarly and popular. Deeply researched, Heely draws from some high-level theory to try and explain the transformation in psychiatric care in the 20th century. However, the scope of the book leads to some organizational difficulties, and Heely's own speculations on what happens next don't quite match up to his research.

David Heely attempts to offer a wide-ranging description of the characteristics of modern psychiatric care, both show more positive and negative. He engages in a historical development of psychiatry through the 20th century, from asylums engaged in confinement, psychodynamic and analytic theories, and finally, modern drug-based psychiatry, as exemplified by the use of chlorpromazine (Thorazine). Heely’s work is theoretically grounded in Foucault’s idea of biopower, the responsibility of states and individuals to engage in the management of health, and Thomas Kuhn’s ideas about paradigmatic science. Psychopharmacology is not dominant because it is more “true” than other forms of psychiatric care, but because it sustains a powerful system of interlocking scientific, economic, and cultural forces. Heely is most skeptical about the power of randomized clinical trials (RCTs)

In brief, the concentrate of the ‘raving insane’ in asylums in the 19th century gave early alienists the human raw material to formulate a wide variety of nosologies of mental illness, and the possible origins behind them. Psychoanalytic formulations a la Freud, dominated the intellectual style of the time. WWI and WWII created massive new systems of psychiatric care for shell-shocked veterans. The expansion of office based psychiatric care post-WW2 enrolled millions of new patients into the mental health system, at the same time as ‘psychobabble’ permeated popular culture, along with the notion that poverty, personality disorders, social stress, crime, addiction, etc were proper areas of expertise for psychiatrists. The expansion of psychoanalysis lead to the anti-psychiatric backlash of the 1960s (the counter-culture trying to decolonize insane minds), severely damaging the paradigmatic authority of psychoanalysis.

Concurrently, in the 1950s, a group of European scientists (Jean Delay, Labriot) were experimenting with a new class of drugs that showed astonishing progress in curing the deeply insane in the back wards. Hopeless patients given chlorpromazine showed remarkable improvements. Scientific theory did not explain the action of these substances, but these neuroleptics cured the raving mad, and demonstrated powerful effects on the mind and body, including tardive dyskinesia and akathisia. Concurrent developments with LSD and amphetamines pointed towards a theory of molecular basis of madness and sanity, but the counter-culture’s embrace of LSD ended its use as a legitimate scientific tool. Instead, experiments with radiotagged molecules proved the existence of neurotransmitter and receptors in the human brain, leading to a host of amine-based theories of madness. Brains are essentially chemical organs, and by adjusting chemical activity through drugs, they can be restored to sanity.

The new practice and theory of psychopharmacology demanded new ways of regulating and using drugs. Relapses on chlorpromazine soon proved to a major problem, reframing the problem of psychiatry away from “showing the patient a moral mirror of himself” and towards ensuring compliance with a drug regime. The thalidomide crisis lead to the 1962 amendments to the Food and Drug Act which established that drugs could only be given by prescription as a treatment for well-defined illnesses. These amendments inculcated a culture of risk management, a drug could be both beneficial and/or harmful in an individual case, but on average, had to help patients.

The 1962 amendments, along with new funding priorities in the NIH, established the randomized clinical trial as the gold standard of efficacy. Heely argues that RCTs are in fact highly flawed instruments for psychiatry, in that their need for objective and portable results relies on symptomatic scales that do not translate to improved patient quality of life. Drugs may vary in effectiveness between patients with different biologies or temperaments, data which is not captured by RCTs.
Additionally, the regulatory environment surrounding medicine means that from a business standpoint, the most sensible policy is to increase the number of people suffering from a given mental illness. The growth in depression, OCD, social anxiety, and ADHD are mirror by increases in drugs to treat those conditions. The immense amount of money flowing from patients to pharmaceutical companies to doctors (see White Coat, Black Hat—Elliot) has effectively corrupted science.

Finally, according to Heely, current theories about the brain are no more well-grounded than Freudian psychodynamics. The idea that a single neurotransmitter path is linked to a defined illness or its cure is not supported by the powerful action of drugs which work on many neural systems, or the way in which a single drug might cure multiple disorders (Prozac is actually not very good at treating classical depression. It works much better on OCD).

Heely leads me to three major questions. First, if we are not going to rely on RCT, what other methods do we have for knowing how to match treatments to diseases to symptoms? The idea of how science should operate, and what counts as science, and thorny and complex. Second, how will the current biological paradigm be replaced? Psychoanalysis was destroyed because it overstepped its bounds without bringing consummate benefits; patients felt oppressed rather than helped. Heely proposes that genetics and brain imaging will upend the biological paradigm, but after 10 years I am doubtful. Thirdly, what is the appropriate place of psychiatric drugs in society? Who should be responsible for their use, and what counts as a treatable condition? If we’re really moving towards an era of ‘cosmetic psychiatry’, what does that imply about the authority of those administering treatments, and what counts as an acceptable risk? show less

Clearly written and never too dry. This does a great service to the subject as a history, and also to Healy's other subject, which is the brave new world we're entering via expansions of the DSM that pathologize human variation, as well as diagnosis by proxy, and drug trials that leave a lot to the imagination.
Fun fact for painters: Carbamazepine was one of a series of tricyclic molecules stemming from the iminodibenzyl dye, summer blue.
Chilling words: "Adolescence has been easy to deal with show more because until fairly recently it was all but standard to view adolescence as a time of semipsychosis, when suicidal ideation or erratic behaviour was common. But this period of turmoil was also seen as a necessary development phase that often laid the basis of later creative genius or other accomplishments. It is not clear what we might lose if marketing departments capture our views of adolescence."
If there's a Joyce among us, we're going to drug him. show less

The idea of outlining the history of "drugs, insanity, and society" and demonstrating "how changes in the relationship between them cause changes in the way we experience our selves" is daunting to say the least. (1) These are the questions and issues David Healy valiantly attempts to address in his 2002 book, The Creation of Psychopharmacology. Despite having shed substantial light on the topic, he falls short of his goals.
The tale Healy tries to tell spans more than a dozen decades and show more several continents. It draws from science, medicine, and industry and deals with issues of society, culture, gender, and class. Undertaking such a far-reaching project demands impressive research skills in a broad variety of disciplines, which Healy undoubtedly possesses. Presenting the results of such a project demands even more impressive organization and communication skills, which Healy may well possess, but which are sadly not demonstrated here.
This poor presentation and lack of organization often make it difficult to absorb the undeniably impressive amount of information the book has to offer. In particular, the time line is often unclear. There are certainly valid reasons for not employing a strictly chronological approach when recounting a complex series of events, but a non-chronological approach does impose particular demands for clarity on the author. It is far too easy for even a careful reader of Healy's book to be uncertain of when a particular event occurred and, more importantly, how it fit into the bigger picture. It is also easy to loose track of the extensive cast of characters. The names of countless chemists, researchers, doctors, therapists, and theorists dot the pages, and it is often difficult to distinguish the bit player from the major one.
Healy also has difficulty striking a balance between providing his readers with a complete account of a complex subject and overwhelming them with scientific detail. Talk of how someone "hung the side chain of chlorpromazine onto a nucleus similar to the phenothiazine nucleus, the imminobidenzyl nucleus (derived from the dye summer blue), and produced the drug imipramine" or of attempts to "improve on pethidine's analgesic effect and speed of action by removing a methyl group from it to make it more fat soluble (lipophilic)" are a bit much for a general audience. (227, 118) The science matters, and it undoubtedly has a place in the account, but Healy's treatment of it is more off-putting than informative.
It is clear that Healy is trying very hard to tell an interesting story, one that is quite relevant to society today. However, his organizational problems and his tendency to provide detail without context make it difficult to notice the most important things he has to offer. They are lost in the background noise instead of commanding the attention they deserve.
In "Mind-Body Problems," the 1999 presidential address to the Spring Meeting of the American Ethnological Society, Emily Martin also considers the interaction between science and society. Although much smaller in scope, Martin's work shares several themes with Healy's, especially the idea that changes in scientific knowledge and changes in how people conceive of themselves are closely related.
Martin chooses to explore this relationship by examining a conflict between "neuroreductive cognitive sciences" (the idea that all kinds of learning are dependent on things happening in the brain, rather than in the culture) and anthropology. (574) She begins by clearly and succinctly laying out the relevant aspects of neuroscience, then outlines the criticisms of neuroreductionism that fit a more anthropological approach. With this background firmly in place, she turns to a search for events in the recent past that could "[incite] a turn to a neuronal account of human consciousness, an account that...erases social context." (577) She sees the reversal of the "gendered associations with the realm of entrepreneurial capitalism" as a prime candidate. (578)
This notion may seem shocking at first, but Martin supports it in a logical fashion. She first shows that he 20th century capitalist ideal was linked with many masculine traits, then establishes that manic states were associated with women, then shows a recent tendency to associate mania with the economy (a 'feminine' trait with a 'masculine' field). She proposes that this is a shocking enough transition that it demands new ideas of the self in which individuals take precedence over societies, a view that neuroreductionism supports by seeing society and culture as results of inherent brain function. The article certainly does not establish this idea beyond any possibility of doubt. It does, however, propose a theory, provide appropriate background, and provide relevant support - all in an orderly fashion without bogging down in extraneous detail.
Both works deal with the complicated relationship between science and society. Both have intriguing insights and information to offer. Healy covers an immense amount of material, but because of poor organization and an over emphasis on minutiae, it is difficult to absorb the most important aspects of his story. Martin's theory, although probably not as strong or as important as Healy's, is clearly presented and very accessible and so more readily understood than Healy's. These pieces serve as perfect examples of just how important presentation is. show less

An indictment of the pharmaceutical industry citing both historical and contemporary examples that also takes a broad look at the medical/industrial/academic complex. Includes suggestions for possible reform.