As one ages, the word history takes on a different meaning, at least it has for me. As a young person, history meant something like it was before my time. But now, it includes my time too. And so my preoccupation these days with the invasion of my medical specialty by the pharmaceutical industry has actually happened in my lifetime, my history, and some of the landmarks have had an impact on my own life [though as they happened, I had no idea how big they really were going to be]. Here’s a unstructured travelogue of some of the landmarks along the way. First, from before my time:
Psychoanalysis: Psychoanalysis arose in Europe in the early 20th century, but it didn’t really come to America in a major way until after World War II when the European analysts [many of them Jewish] fled Europe escaping the Nazis. Psychoanalysis, as one of the first "talk therapies," had a big influence on Psychiatry in America in the post-war era and beyond.
Psychiatry: The medical specialty, Psychiatry, is a relative newcomer – arising from Neurology [the Boards are still joined]. In earlier times, what we now call Psychiatrists were called "Alienists" [a testimony to older views of mental illness]. Some of the rise of Psychiatry was influenced by Psychoanalysis, but there were other factors. American Psychiatrists [people like Adolph Meyers and Harry Stack Sullivan] were developing psychotherapies on their own. And then there were treatments – fever therapy, lobotomy, ECT, Insulin Coma Therapy – they seem bizarre now, again, a testimonial to the desperateness of some of the Psychiatric illnesses like Chronic Schizophrenia.
Pharmacotherapy: Probably the biggest drug in the history of Psychiatry was penicillin [the late 1940’s]. It eliminated the most prevalent mental illness – tertiary syphilis. Then, in the 1950’s, came the phenothiazines, the first antipsychotics; Lithium, the first antimanic; and the MAO inhibitors and Tricyclics, the first antidepressants. Variations on those themes is where things were when I came along in the 1970s.
Community Mental Health:In World War I, there was an epidemic of a new mental illness called "shell shock" or "traumatic neurosis," and it didn’t go away [now called PTSD -Post Traumatic Stress Disorder]. When World War II came along, the Military screened recruits for mental problems [thinking PTSD was a symptom of previous problems]. That was dead wrong, the incidence of War Neorosis remained hidh early in the War. Then they came up with a new idea – Combat Fatigue. If you showed signs of mental problems, you were sent way behind the lines out of battle, fed well, allowed to rest, got to talk to a psychiatrist. After a few days, back you went to the front lines. It was a raging success – quadrupling the soldiers that could be sent back to the battlefield. That became the discipline of Crisis intervention – prevention of mental illness. At the same time, the introduction of antipsychotic medication meant that many of the patients in State Hospitals ans Sanatoriums could be sent home. So, in the 1960s, the Government funded the Community Mental Health Act, and money flowed to Community Mental Health Centers and Mental Health Training. With early intervention and the new medications, we were going to nip mental illness in the bud and shut down the old Mental Hospitals for good.
When I came to Psychiatry, it was because I was interested in the "mind" and psychoanalysis. That interest had little to do with public mental health, it had to do with my own curiosity [and maybe my own mental health too]. But in training, I got with the program and involved myself with Crisis Intervention and drug treatments, even though my own interest was psychotherapy – the talking thing. By that time, the chronic mental patients were on the streets, and the funding from the Kennedy/Johnson years had been slashed by the Nixon Administration. The rhetoric of Early Intervention was still alive, but with dwindling resources it was becoming an increasingly empty metaphor. And so a lot of Chronic Mental patients had moved from the State Hospitals all right, but into the ranks of the "homeless" – a group formerly populated by chronic alcoholics and addicts.
In an earlier post, I mentioned paradigm shifts [fickle science: fads, and paradigms…]. When I showed up in Psychiatry, they were shifting seismically. Community Mental Health and Psychoanalysis were on the wane. Antipsychotic drugs had emptied the Mental hospitals, and drugs were going to do even more, or so everyone thought. There were a couple of other things happening too. Managed Care was on the ascendancy. It’s focus was on cost effectiveness – and no "talking therapy" is cost effective – inpatient or outpatient. And by this time, there were plenty of "talking therapies" from other disciplines. You want to talk? Pay for it yourself. So mental health benefits in Insurance Policies were slashed. You got a few sessions to get on medication, then you were on your own. Another factor in the rise of drug research was the policy on generic drugs. If you were a pharmaceutical Company, you got only a few years of exclusivity [a patent], payback for having developed the drug, then anyone could make it. So profitability became time limited.
In all of these cases, each paradigm was developed in a limited setting, then generalized and pushed into areas that were beyond its usefulness – sometimes way beyond. But it’s easy to see why drug therapy was on the rise, and easy to see why the pharmaceutical companies were searching for new drugs. In retrospect, it was a Perfect Storm, just right for what was about to happen. Then there was a "breakthrough" called Prozac. It was introduced in 1987, and followed by a host of others similar drugs [Selective Serotonin Re-uptake Inhibitors – SSRI’s]. These drugs, unlike the ones mentioned above, were effective in a wide variety of situations of lesser magnitude than the Major Mental Illnesses like Schizophrenia or Manic Depressive Illness. They were helpful in depression and compulsive symptomatology in more "regular" people. So the Age of Psychopharmacology was launched full bore.
I’ve mentioned how these changes affected my career elsewhere. But I’ve posted this narrative to roughly explain why the situation we’re now observing was probably inevitable. The promise of an inexpensive drug therapy [quick fix], the need to patent new drugs, the waning funds to pay for training, the sad fate of mental health care at the hands of Insurance Providers, even the post-Hippie drug culture created the environment where pharmaceutical company driven "drug trials" offered everyone a lot. Then, as happens with any new paradigm, it became way over-utilized.
What was different here was that the opportunity for corruption was huge with so much money involved. In my last post about Drs. Borison and Diamond, it was exaggerated corruption – just plain crime. But in the other flurry of posts recently [Nemeroff, Schatzberg, etc.], the corruption is less obvious – embedded in CME presentations, grantsmanship, donations, speaker’s bureaus, marketing strategies, etc. – but corruption none-the-less from my perspective. The proliferation of oversight groups and government investigations is hopefully the marker for the decline of the pills for all ills paradigm, but it still leaves the problems that promoted it in the first place – the chronic underfunding of public and private mental health care and training. Right now, that storm is still raging, blown about by forces with way too little focus on the real problems – the problems of the mentallly ill people it purports to serve.
Excellent post. Thank you so much. The consequential actions of some unscrupulous doctors and drug companies are to be taken and dealt with seriously and diligently so that the real problems are efficiently tackled.