Good science or good business?

When Listening to Prozac emerged in 1993, it was one of the few books dealing with psychiatry to become an international best-seller since Freud's and Jung's works and the only book on psychopharmacology ever to do so. The book dealt with the effects of an "antidepressant" on conditions that often looked more like states of alienation than classic depressions. For many, this was their first awareness that antidepressants were drugs distinguishable from minor tranquillizers. For others, Peter Kramer's book and the notion of cosmetic psychopharmacology that it introduced raised interesting ethical and philosophical dilemmas. But the argument here is that the attraction of the book has depended on a series of engineered transformations in the way we think about mental well-being. The "alienation" Prozac and similar therapies "treat" has very commonly been defined in terms of the interests of the medico-pharmaceutical complex, and the arguments on offer about the merits of Prozac look more like descriptions of the interests of their proponents than dependable accounts of reality. The interface between mental health and alienation traces to the emergence of psychodynamic therapy at the turn of the century, but this new industry remained at one remove from psychiatry until the 1950s. While the therapists took charge of such problems as alienation, psychiatrists dealt with those suffering from full-blown psychoses. In the interim, there was considerable recourse to do-it-yourself pharmaco "therapy" that employed alcohol, opiates, bromides, and barbiturates to manage community nervousness (that is, nervous conditions that do not lead to hospitalization), but this use, unconstrained by a therapy establishment, gave rise to little talk of alienation among philosophers. Indeed one can wonder whether many philosophy departments would be able to function without alcohol to facilitate social intercourse. When imipramine, the first antidepressant, was introduced, clinicians and pharmaceutical company executives could see little rationale for it. The frequency of affective disorders appeared vanishingly low and these conditions responded to antipsychotics or ECT. Clinicians used the antidepressants sparingly,[1] and the very word "antidepressant" only begins to appear in dictionaries in the mid-1980s. Unlike the antipsychotics, the antidepressants had no clear niche. However, they did seem capable of making some difference to a large number of people, even if those people might have to be persuaded that they needed this difference in their lives. As early as 1958, Roland Kuhn, the discoverer of imipramine, had noted that some sexual perversions responded to imipramine and that many patients, when they recovered, felt better than well.[2] Such transformations opened up significant philosophical and ethical issues--claims now strongly suggestive of Kramer's agenda. But whereas Kramer's book became a runaway best-seller, Kuhn's speculations had minimal impact. The philosophers who were excited by the new psychotropic compounds in the 1950s and are now interested in neuroscience and Prozac were not interested in imipramine. Market Development The developmental trajectory for the antidepressants was largely determined by a critical external event--the thalidomide disaster. The public reaction to the birth defects caused by thalidomide, which had been taken by pregnant women to combat "morning sickness," led to the 1962 Food and Drug Act amendments, which channeled drug development toward clear diseases. Drug availability was restricted to prescription-only medicines, placing it in the hands of individuals who supposedly would make drugs available for problems stemming only from diseases rather than for those stemming from other sources. These developments radically changed psychiatry, first by putting a premium on "categorical" rather than "dimensional" models of disease, so that psychiatrists were more likely to treat diseases as conditions that patients either have or lack rather than have to some degree, and second because prescription-only status brought nervousness within the psychiatric ambit. …