David Healy. The Antidepressant Era. Cambridge: Harvard University Press, 1997. x + 317 pp. $39.95 (cloth), ISBN 978-0-674-03957-5.
Reviewed by Catherine Calloway (Arkansas State University)
Published on H-PCAACA (May, 1999)
The sudden emergence of modern medication after World War II, when specific illnesses first received specific treatments, is the focus of David Healy's book The Antidepressant Era. Well written and thoroughly researched, the book provides an excellent overview of the history of psychotropic medicine from Hippocrates to the age of Prozac, using depression as a paradigm of the ways in which the popularity of such drugs may have been influenced more by pharmaceutical marketing rather than by medical necessity. What disturbs Healy, a previous secretary of the British Association of Psychopharmacology and the current Director of the North Wales Department of Psychological Medicine at the University of Wales College of Medicine, is that as the discovery and marketing of antidepressants have increased so have the cases of diagnosed depression and other related disorders, such as social phobias and obsessive-compulsive disorder, as well as the number of prescriptions written. Healy thus questions the role that pharmacologists play in changing people's perceptions of illness and in making certain diseases so popular that they acquire their own biological language and become icons of popular culture.
Chapter One traces the history of diseases, illnesses, and remedies, beginning with the philosophies of Hippocrates and Galen of Pergamon and concluding with the 1950s and the emergence of a diagnosis-oriented medicine. Healy shows how the study of medicine evolved from the humoral system, which centered around why one was ill, to the present system, which focuses upon how particular illnesses occur and how to best treat them. In Chapters Two through Six, Healy chronicles the discovery and development of antidepressants, the significance of double-blind randomized placebo-controlled drug trials, the ways in which the study of psychiatry and the development of medication have become standardized, the advent of a biological, psychiatric language, and the effects of pharmaceutical maketing strategies.
While Healy addresses a more professional than general audience, the book still offers much for the lay-reader. Healy takes care to define medical concepts and terminology throughout the text. He explains, for example, the ideas behind interpersonal theory, the neo-Kraepelinian movement, Eysenck's personality theory, the 1970s emphasis on receptor theory, the Oedipus, Luke, and Matthew Effects, and pharmacological Calvinism. He also details the many key figures involved in the development of modern psychiatry, such as Adolf Meyer, Emil Kraepelin, Nathan Kline, Bernard Brodie, and Gerald Klerman. Throughout The Antidepressant Era, Healy reveals some interesting facts that even readers possessing some familiarity with psychotropic medications may not know. For instance, both Prozac and Clozapine were developed a number of years before they were marketed, and the first antipsychotic medication was chlorpromazine.
A major issue that emerges in Healy's discussion concerns the type of treatment best suited for psychiatric-related disorders. A conflict exists as to which is most effective: drug treatment or psychotherapy. Should mental illnesses be considered neurological brain disorders and thus actual diseases that should be treated with medication, or is medication merely a substitute for evading the reality of life's problems? Could, in fact, psychotherapy replace much of the medication currently being prescribed? Unfortunately, Healy limits himself to one main example, the two-decade old Dr. Rafael Osheroff case, detailed in Chapter Seven, which focuses on a patient who was treated as having a personality disorder rather than the depression he was initially diagnosed with and who received only psychotherapy while hospitalized for seven months in 1979. The denial of drug treatment during that hospitalization resulted in the degeneration of Dr. Osheroff's health and the loss of much of his personal and professional life. The Osheroff case spawned much critical debate, especially between two leading figures in psychiatry, Gerald Klerman and Alan Stone. Klerman advocated randomized control trials and more patient participation in choice of treatment, especially since drug therapy is regulated by the Federal Drug Administration, while Stone argued that there was no real evidence that psychotherapy was less effective than drug treatment.
Healy's book leads one to wonder if medical advances are really so determined by political and financial factors and if highly trained physicians, as well as the general populace, are indeed so susceptible to clever marketing ploys. Would the majority of today's psychiatrists, if surveyed, consider themselves so vulnerable to the influence of the pharmaceutical industry? In addition, while Healy admits that it has never been proven that psychotropic medication has been overprescribed, he only hints at the possibility that it may have been underprescribed. Perhaps the symptoms were there all along and merely went unrecognized by general physicians who had little training in psychiatry. Mental illness has long been an unpopular topic, subject to being placed on the back-burner or hidden in the closet. Many who take psychotropic medications have been stigmatized by society and denied full medical coverage by insurance companies who refuse to recognize their illnesses as valid diseases. Perhaps we should thank the pharmaceutical industry for making us more aware that mental illnesses do exist and are treatable with drug therapy.
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Catherine Calloway. Review of Healy, David, The Antidepressant Era.
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