Edward Shorter: The Rise and Fall of the Age of Psychopharmacology
Barry Blackwell’s comment
In 2020 I decided to write a book originally intended to be a compendium of biographies of selected pioneers in psychopharmacology and early controversies in the field based on my work as an editor for the INHN website founded in 2013 by Tom Ban.
In my Prologue I explain how this morphed into something more substantial and significant influenced by the historical material and my career as a psychopharmacologist. I noted that the evolution of the discipline could be divided into two distinct time periods: 1949-1980 (The Pioneer Period) and 1981-the present (The Modern Era).
Originally titled Treating the Brain this comparison led me to describe it as an odyssey, adding that to the book’s title (Blackwell 2020). The OED defines odyssey as, “a long and adventurous process.” In retrospect a trivial, perhaps romantic title for a far more tragic and sinister event with profound implications.
Edward (Ned) Shorter was kind enough to write a Preface to my book and while he agreed with the two periods and their labelling, his experience as one of the world’s leading historians of psychiatry and his expansive data base led him to recognize the far larger significance, scope and severity of the difference now documented in The Rise and Fall of the Age of Psychopharmacology.
Purpose of the Book
In the Preface to his own book Ned expresses his main concern, “People still take drugs for the brain and mind that often work but the science has gone out of it.” As a historian he traces this from “the relative dignity and arms-length relationship between industry and academy in the 1960s to the invasion and capture of academic psychiatry by the industry in the 1990s. How did this decline occur?
Ned answers his own question. “The rise of psychopharmacology was a brilliant event but its fall has resulted from the triumph of commerce over science.” He names this “the degradation of psychiatry as a clinical discipline” and identifies two major contributory causes, diagnosis and treatment. The former is “The DSM calamity” dating from DSM-III in 1980, “a monstrous compilation of artifacts and half diagnoses.” The latter contrasts the appropriate and effective use of imipramine, chlorpromazine and the MAOIs for “sturdy clinical diagnoses” contrasted with the less effective but relentlessly marketed SSRIs and second generation antipsychotics for consensus driven DSM disorders.
So, psychopharmacology has evolved from “a rigorously scientific discipline” to become a “a commercial trope for selling drugs; wide-eyed speculation about neurotransmitters and receptors and jury-rigged trials replace scientific evidence.”
Structure of the Book
The chapters are divided into 3 parts.
Getting Going (Ch.1-6)
Science Disaster (Ch. 16-21)
There are 21 Chapters (pages 3-326) and 81 pages of End Notes, comprising almost 1000 references and citations spread among the chapters.
Chapter Titles (No. of citations in parentheses)
1. Introduction (32)
2. Before Psychopharmacology (43)
3. The Rise of Psychopharmacology (73)
4. Things get Rolling (67)
5. Depression & Schizophrenia (75)
6. Industry- Early Days (94)
7. DSM (107)
8. Science (71)
9. KOL’s (119)
10. Trials Begin (56)
11. Fantasy Patients & Fantasy Diseases (55)
12. Trials: Industry Takes Over (26)
13. Marketing (132)
14. Journals (36)
15. FDA (51)
16. Prozac and its Cousins (127)
17. Sally- Turning Depression into a Gold Mine (76)
18. Atypicals- Lousy Treatments (122)
19. Texas Algorithm Project- TMAP (29)
20. The Fall of Psychopharmacology; weak, delusional theories (70)
21. Conclusions (12)
22. END NOTES 329-410
23. INDEX 411-431
A Tour de Force
Familiar as I am with the same territory covered by Ned I am filled with admiration for the fresh insights and scholarly background with which he has clarified and amplified the issues dealt with in our two books. I suggest every psychiatrist who prescribes not only should but must read it.
Beyond that there are two issues worthy of further comment.
A Missing Piece
In my own book I use the word “stagnation” to describe the Modern Era. Ned cites this to distinguish what is true of the drugs developed but not of the physicians who prescribe for two reasons. First, their experience; “old hands develop a sense of which drugs work on which patient.” And second, “Because of the trust built up in the doctor-patient relationship.” But add to this the Hippocratic aphorism, “keep watch on the faults of the patients, which often make them lie about taking things prescribed.” In the early days of modern medicine this was coded as “Patient Drop Out,” until in the mid 1970s when two Canadian Psychiatrists at McMaster University in Toronto (Haynes and Sackett) coined the word “Compliance” and initiated two World Conferences in 1974 and 1977, both of which I attended together with other psychiatrists interested in “non-drug factors” influencing outcome. This sparked a vibrant research literature of up to 700 articles a year. In 1996 John Talbott invited me to edit a book on the topic for a series on Chronic Mental Illness. Volume 5 was titled Treatment Compliance and the Treatment Alliance (Blackwell 1997).
My opening chapter “From Compliance to Alliance”; A Quarter Century of Research” was a review of the 12,000 articles published in the previous quarter century. Psychiatry and Pediatrics were the top two disciplines (tied at 11% each). A subsequent Chapter, “The Physician who Prescribes,” dealt with features of the therapeutic alliance. Psychosocial features that influenced outcome including the physician, the patient, the illness, the treatment regimen and the support system.
By and large industry ignored the bulk of non-biological research although for a short time I became a KOL recruited to train ophthalmologists how to persuade their patients to use eye drops. Doctors of all disciplines tend to over-estimate compliance, but some more than others.
Other chapters in the book by consumers or experts in the field dealt with schizophrenia, bipolar disorder, the elderly, developmental disorders, cultural diversity and the role of family members, pharmacists, community mental health workers and case managers.
All this is intended to strengthen Ned’s point that therapy is contributed to by the psychosocial aspects of treatment as well as effective and ethical chemotherapy, the biological component.
What to Do?
Ned’s answer to this question is just over a page long with three components.
1. Restoring a government run drug testing program that usurps control from industry.
2. Taking control of diagnostic systems away from the American Psychiatric Association and placing it in an independent scientific organization.
3. Making psychiatric treatment a public health issue designed to restore an integrated biopsychosocial model by strengthening the psychosocial component and removing over aggressive and ineffective biological drug therapy.
While I agree with and support these suggestions they are imbedded in a much larger and intractable Zeitgeist that requires economic, political and social change difficult to accomplish and which engenders a mindset of hopelessness and apathy.
My own Final Word is less than a page long and begins with the following paragraph (Blackwell 1997).
“Since 1980 and eight years of Republican politics we have been living in a rapidly evolving culture of social, political and economic change characterized by income disparity, corporate greed and addiction to money, facilitated and condoned by legislative gridlock in which rigid ideology and lack of compromise block consensus for change. This has enabled a corrupt pharmaceutical company, a weak FDA, and a “not for profit” health care system that is the opposite of what it claims to be, in tandem with heartless insurance agencies. All this is coupled with corrupt academic or professional organizations and journals that condone or ignore “conflicts of interest” and have suborned scientific integrity. The sum and total impact of this environment is a stultifying paralysis of will, lacking desire or ability to attempt remediation.”
Blackwell B. Treating the Brain: An Odyssey. Cordoba, INHN Publications; 2020.
Blackwell B, editor. Treatment Compliance and the Therapeutic Alliance. The Netherlands, Harwood Academic Publishers; 1997.
February 3, 2022