The Creation of Psychopharmacology, by David Healy

How the big drugs firms are killing psychiatry

David Healey is a respected historian of psychiatry who has written a book that should spark a major debate. He identifies current trends towards the abandonment of independent research into treatments for mental illness, the demand for Randomised Control Trials as the only acceptable measure of whether a treatment works, and the chilling control pharmaceutical companies now exert over psychiatry.

There may be worse to come. US corporate "managed care" is moving into health systems throughout the world, with a sharp division between medically-trained (and well-paid) physicians who prescribe drugs and (moderately-paid) therapists. As Healey's exquisitely detailed history makes clear, the most effective treatments have been a mixture of both.

Now that the more debilitating mental illnesses are managed through chemical treatments, he cautions that psychiatry is moving towards managing personality. "Why should a physician with no ethical training have the ability to decide whether taking a pill that makes one less sensitive to work-related stress is a good idea?" Physicians prescribing, for example, Ritalin to children, do not think of the social consequences.

These changes, he argues, result from developments in psychiatry that have led North America and Europe to a dangerous place: "we are becoming less rather than more rational".

One form this irrationality takes is that drugs are prescribed to treat the symptoms of a psychiatric syndrome without having been proven effective. Healey argues that an anti-depressant such as Prozac falls into this category. None of the SSRIs (selective serotonin reuptake inhibitors) has shown anything other than weak and unpredictable effects on depression. But they have shown a consistent effect in delaying orgasm in men, and could be used to treat sexual dysfunction. The reason they won't is due to the strangleholds of marketing and licensing.

Psychiatry's championing of chemical treatments over all else began with the breakthrough drug chlorpromazine. It "completely eliminated the original form of insanity" from the 1940s onwards. The irony is, however, that in 2000 there has been a 15-fold increase in rates of admission to psychiatric wards compared to 1900.

Society's reliance on psychotropic drugs may have produced further problems that have been mistakenly blamed on the disease rather than treatment. There have been numerous law suits in the US after patients on Prozac committed violent acts. "The rhetoric of modern drug development is powerful enough to blind clinicians to preventable deaths and obscure the fact that the life expectancies of their patients are falling," writes Healy.

This is an important and thought-provoking book. The author seems, however, to be writing more for the informed rather than lay reader. But Healy's warning that, without a debate, we may be moving into an era when cosmetic psychiatry will be the new liposuction is worth heeding.