Psyccritiques - psychopharmacology and depression

Psychopharmacology and Depression
Before Prozac: The Troubled History of Mood Disorders in Psychiatry
New York: Oxford University Press, 2009. 304 pp. ISBN Medical historian Edward Shorter notes that drugs are labeled for marketing and governmentregulation, not medical usefulness, and in Before Prozac: The Troubled History of MoodDisorders in Psychiatry he argues that this is why no progress has been made in psychiatrictreatment since the 1950s. Shorter believes old drugs—amphetamines and barbiturates,tranquilizers such as Librium and Valium, antidepressants such as Marsilid, andantipsychotics such as Thorazine—were far more effective than anything available today.
So why did all those great drugs disappear? According to Shorter, some went off patent, thus becoming unprofitable and were no longer marketed, but many were regulatedout of existence by the Food and Drug Administration (FDA), leaving, in his view, onlydrugs such as Prozac and other virtually useless antidepressants.
That is a radical thesis, to say the least. Does Shorter convince the reader? He convincingly describes the methods by which physicians are persuaded to use more profitable but less effective drugs. He also gives a compelling history of numerouspsychiatric drugs being removed from the market by the FDA when they were deemeddangerous. But is it true that, as a consequence, the psychiatric pharmacopeia today isuseless? This is not supported by the facts.
Nevertheless, Shorter puts forth that non sequitur by narrowing the discussion from a general history of psychopharmacology to his idiosyncratic definition of depression as anorganic condition best treated by electroconvulsive shock therapy (ECT), not drugs. Heimplies that all other mood disorders are suspect, defined only by the drugs designed to treatthem. Thus, when drugs disappear, the disorders they treat also disappear (e.g., “nerves,”“melancholy”). When new drugs are produced (such as Prozac), new disorders are inventedto fit the new medications (e.g., “major depression”). Shorter does not make this claimdirectly but suggests and implies it without clear logic.
How Drugs Rise and Fall
Shorter claims that the marketing of psychiatric drugs has always been about profits,irrespective of whether the new drugs work better than those they replace. Psychiatrists areas susceptible as anyone to marketing, so new, less effective but more profitable drugs forceout older drugs that may have been superior to the ones that replace them. Good drugs arealso driven out by government regulation.
For example, the barbiturate phenobarbital was an anticonvulsant that was also used as a sleep aid and for the treatment of “nerves,” tension, and sometimes depression andmania. Barbiturate sedatives were overprescribed after 1945, despite their known tendencyto enhance suicide risk, but Shorter says that the absolute number of suicides was low andwas outweighed by the medical benefits that the drugs offered.
Shorter claims that the risk of addiction was also known, but it was lower than the risk of addiction to alcohol. In 1972 the U.S. Department of Justice classified barbiturates asSchedule II controlled substances, alongside narcotics, which removed them from themarket. According to Shorter, this unnecessary action resulted in a serious loss to psychiatryand medicine; it was a politically motivated response to public hysteria about addiction andsuicide and was not based on medical facts.
Shorter tells a similar story for amphetamines (Benzedrine, Dexedrine), meprobamate (Miltown), benzodiazepines (Xanax, Librium, Valium), monoamine oxidase inhibitors(MAOIs; Marsilid), chlorpromazine (Thorazine), and many other drugs. Repeatedly, a drugwas found useful for several conditions, was discovered to have side effects, then wasbanned by regulators with little concern for scientific facts, clinical practice, or societalbenefit. Although these drugs had side effects, this problem would have been better addressed with risk–benefit analysis rather than with knee-jerk condemnation. It doesn’tmake sense to ban drugs, especially whole classes of drugs, on the basis of emotions.
This is a reasonable conclusion. Sunstein (2005), among others, has argued strongly for cost–benefit analysis over fear-based precautionary reactions in government policy, andShorter’s history illustrates that argument. Yet democratic governments must respond topeople’s fears, irrational or not; this is a fact that Shorter does not consider.
Imperial FDA
Shorter is less convincing when he recounts the battle between the FDA and thepharmaceutical industry, describing the 1962 Congressional requirement that drugmanufacturers prove that their products are both safe and effective, after which the FDAaggressively pursued the efficacy requirement. One can guess that the intent was to preventdrug companies from marketing miracle cure-alls, like the patent medicines of the 19thcentury. But Shorter uses opinion, innuendo, and ad hominem comments to argue that themotivation was bureaucratic self-aggrandizement—for example, FDA officials drunk withpower set on humbling the pharmaceutical industry.
His accusations and claims are footnoted, but, upon reading the footnotes, one finds that the vast majority are unsubstantiated opinions. There are hardly any citations ofpublished news stories, judicial rulings, legislative documents, or peer-reviewed scholarlysources.
DSM Wars
Shorter does a similar hatchet job on the academicians responsible for the third edition of theDiagnostic and Statistical Manual of Mental Disorders, released in 1980 (DSM–III;American Psychiatric Association, 1980). Psychiatrist Robert Spitzer headed a core group ofphysicians and scientists from Washington University and the New York PsychiatricInstitute. Shorter says Spitzer “saw the clinicians at Wash U almost as special chums, soulmates to help him against the bad guys” (p. 156). Psychoanalysts were the bad guys. Shorterclaims that Spitzer et al. were determined to eradicate the fanciful distinction betweenneurosis and psychosis and to eliminate unproven etiologies. But the psychoanalysts foughtback. As a result, the DSM–III ended up being “a political artifact born of academicinfighting” (p. 10).
Why does it matter? Because, Shorter says, if a diagnostic schema is based on politics rather than “nature,” then treatment is arbitrary. That would be true if the DSM–III classifications, especially for mood disorders, were invalid, but Shorter does not providesubstantial proof for such a claim.
The FDA’s definitions are also arbitrary, he believes: So keen was the FDA to limit the label of drugs to indications sanctioned by [government] panels, that the bureaucrats increasingly saw “depression” as the one indication that seemed solid amidst the tossing overboard of “nervousness,” “hysteria,” and the like. . . .
Control of the label, in this case, turned out to mean control of the field, which increasingly became the “antidepressant” field. (p. 149) Shorter does not make a connection between the government review panels and the DSM–III, but he concludes, “Bottom line: Major depression doesn’t exist in Nature” (p.
165).
Shorter proposes instead two tiers of mood disorder that should be called melancholic disorder and nonmelancholic disorder; this terminology is based on the ancient theory ofhumors (melancholy being caused by an excess of black bile). He explains that melancholyis a biological disorder that is what used to be called endogenous depression, whereasnonmelancholic disorder is merely a situational (reactive) low mood (p. 14).
The ECT Connection
Shorter takes the melancholia terminology from Max Fink, a prominent psychiatricresearcher and author (p. 272, Footnote 2). A well-known advocate for ECT (Kaplan, 2005),Fink is the author of books and articles advocating ECT (e.g., Fink, 2002) and the founder ofthe Journal of ECT, in which Shorter occasionally publishes. Fink’s private foundation, theScion Natural Science Foundation, funded Shorter’s earlier book on ECT that was writtenwith David Healy, head of an ECT treatment unit at Cardiff University (Shorter & Healy,2007), and also partially funded Before Prozac (p. 289). Fink also collaborated with Shorteron Before Prozac (p. 165).
The connection between Shorter, Fink, and advocacy for ECT is thus discoverable but not clearly identified in Before Prozac, although Shorter does state, “Electroconvulsive(‘shock’) therapy, originated in 1938, remains the most effective treatment of serious,melancholic depression” (p. 48). Enthusiasm for ECT connects Shorter’s loosely relatedarguments.
He has a dim view of SSRI antidepressants and the FDA policies that—in his view—forced the pharmaceutical industry to produce them to the virtual exclusion of allelse, even though they are ineffective in treating melancholia (p. 193), which calls for ECT,he says. A bias for ECT could also explain his theory that a cabal “invented” major depression, causing that diagnosis to have “taken over virtually the entire practice ofmedicine” (p. 169) and making SSRIs the treatment of choice.
Shorter’s thesis seems to be that while melancholic depression is a particular biological disorder best treated by ECT, everyone has been deluded by the DSM, the FDA,and big pharma into thinking that depression is a diffuse category of disorders for whichSSRIs are the best treatment, even though they are based on a false theory and are no moreeffective than placebos.
However, Shorter fails to make a convincing case that he is right and everybody else is wrong. A scattershot of bombastic arguments does not provide enough evidence for one toreject most contemporary theories about the efficacy of psychopharmacology. Anotherpossible reason for the book’s lack of coherence is that it is a mere collocation of pointsalready made elsewhere (e.g., Healy, 1999, 2004; Shorter, 1997; Shorter & Healy, 2007) andpresents few new ideas.
That said, Shorter’s history of psychopharmacology in the United States since 1938 is engagingly written and informative. The reader should know a little aboutpsychopharmacology to get the most out of the story, although the book does have a tablelisting the generic and trade names of each drug discussed and a glossary of biochemical,pharmacological, and diagnostic terms. Because Before Prozac is not an impartial history, Irecommend it only to well-informed mental health professionals and for students only in thecontext of broader discussion.
References
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
Fink, M. (2002). Electroshock: Healing mental illness. New York: Oxford University Press.
Healy, D. (1999). The antidepressant era. Cambridge, MA: Harvard University Press.
Healy, D. (2004). The creation of psychopharmacology. Cambridge, MA: Harvard Kaplan, A. (2005, September 1). Through the Times with Max Fink, M.D. Psychiatric Times, 22(10). Retrieved March 30, 2009, from Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the age of Prozac.
Shorter, E., & Healy, D. (2007). Shock therapy: A history of electroconvulsive treatment in mental illness. New Brunswick, NJ: Rutgers University Press.
Sunstein, C. (2005). Laws of fear: Beyond the precautionary principle. Cambridge, England: August 5, 2009, Vol. 54, Release 31, Article 4

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