Unit 4  Section 1 Exercise 6 Societal Attitudes Cosmetic psychopharmacology and human enhancement
This exercise focuses only on select societal issues relating to treatment of depression. For those interesting in exploring the societal implications of other mental health issues, please link to Unit 8, Medicine and Society.
It is well-established that antidepressant medications are beneficial in treating depression. However, where do we draw the line? There has always been a tendency for these medications, and others like them, for example attention-deficit medications, to become medications in search of a disease. This means that relatively well individuals use psychiatric drugs to modulate mood and performance. One might say in this context, these treatments are similar in nature to superficial cosmetic enhancements. For that reason, it is recommended that the readings below and on the next page are read in conjunction with Nathanial Hawthorne's short story, "The Birth Mark," which you can access in Unit 8.
Read the following excerpts, one from “A History of Antidepressants” from E. Shorter’s History of Psychiatry and a second from Kheriaty’s Cosmetic Drugs Paper (& link to paper on Metanexus website) answer the study questions. Continue to the next page for additional exploration of this topic.
Edward Shorter, from History of Psychiatry
When Peter Kramer, a psychiatrist at Brown University, coined the delicious phrase, “cosmetic psychopharmacology,” in 1990, he was applying it to a new antidepressive drug the Eli Company had developed called Prozac (fluoxetine). Kramer came in for much scorn in hyping a drug that, he claimed, made patients feel “better than well.”
Yet the symptoms of depression and anxiety that Prozac and similar drugs treated were not trivial affairs. The NCS study found that within the previous 12 months, 10.3 percent of all Americans had a major depressive episode, and that on a lifetime basis 19 percent of the population—1 person in 5—would undergo an often-disabling mood disorder. Almost 20 percent of the entire population had experienced a phobic disorder such as agoraphobia, fear of open spaces, within the previous 12 months; and almost 1 in 20 would feel a generalized kind of anxiety . Such conditions were, in other words, extremely common, and those suffering from them were entitled to help rather than ridicule for their failure to pull up their socks.
There is no doubt that psychotherapy helped patients feel more comfortable with their psychiatrists, in contrast to the old-style alienists with their lack of interest in the complexities of the human spirit. Yet lifting symptoms rather than cultivating a sympathetic rapport in the office remained the ultimate therapeutic objective. And problems that had their origins in the brain would find their remedy in drugs that acted on the rain’s chemical receptors. This was the good news for psychiatry: that a new panoply of drugs made it possible to help people with garden-variety anxiety and dysphoria, as opposed to the major psychiatric illnesses for which the antipsychotics, tricyclic antidepressants, and antimanic drugs stood ready.
The bad news was that by the end of the 20 th century these drugs had acquired such currency that, much as in the 18 th century, patients began to view physicians as mere conduits to fabled new products rather than as counselors capable of using the doctor-patient relationship itself therapeutically. With the introduction of cosmetic pharmacology, medicine had come full circle. In olden times, patients had often been impatient with physicians, seeing them mainly as boil-lancers and enema-givers whose main resource lay in being able to write a prescription for a very powerful laxative Moliere Dom Juan the kind of therapy that traditional patients coveted. In the world of postmodern medicine as well, patients often resented doctors for their real or imagined shortcomings, and saw the consultation mainly as a way of getting a prescription for drugs that they, the patients, had already pretermined were the anser to their problems. Physicians in primary care experienced this drug-seeking around requests for penicillin and other antibiotics. In psychiatry it was experienced as patients’ demands for Valium and Prozac.
Psychoactive drugs have always been available in one form or another to help people deal with depression and anxiety. Alcohol, which acts initially as a stimulant than a depressant, is as old as time. Opium achieved currency in the eighteenth century, and its alkaloids were used medically for depression in the nineteenth. The barbiturate sedatives had been available since the turn of our own century. Yet all had disadvantages in terms of addiction, daytime sedation, and inability to life the core symptoms of psychiatric disorder.
Here, Shorter goes on to describe the development of “Miltown” (meprobamate), a tranquilizer. This was followed by the development of Valium.
Valium was the next frenzy. Competing pharmaceutical houses had been observing intently the emergence of chlopromazine and Miltown. In 1954, Hoffman-La Roche, a Swiss-based drug house with a large American office in Nutley, New Jersey, instructed its organic chemists to develop a “psychosedative drug.”
Interestingly, neither university scientists nor governe\ment grants were involved in any of this: It was all driven by the profit motive. As Irvin Cohen, one of the psychiatrists who first tested Valium’s sister drug Librium later reflected, “The benzodiazepine [Valium etc.] story is essentially a model of how a therapeutic agent is conceived and brought forth by an enterprising pharmaceutical manufacturer who simply seeks to find a drug superior to others already in the marketplace.” Thus Roche was merely hoping that its organic chemists would bring it abreast of the game….
In January 1959, Roche’s medical director persuaded a few psychiatrists to try chlordiazepoxide on some of their office-practice patients. The patients did very well, becoming much less anxious and tense, and sleeping better. Emboldened by the enthusiasm of the psychiatrists, Roche marketed chlordiazepoxide oin February 1960 under the trade name Librium. It was the first of the benzodiazepines, or “benzos,” and during the 1960’s was the number one prescription drug in the United States. Ultimately, there would be more than a thousand kinds of benzos on world markets.
Yet Librium had a number of side effects and could cause fits if suddenly discontinued. Roche felt the series Sternbach was working on had further potential. He was sent back to the lab bench. In 1959, he came up with a related benzo, diazepam, that was considerably more potent and that could be stabilized in pills. Roche marketed diazepam in 1963 as “Valium,” which until the introduction of Prozac was the single most successful drug in pharmaceutical history. In 1969, Valium surpassed Librium as number one on the American drug list. By 11970, one woman in five and one man in thirteen was using “Minor tranquilizers and sedatives,” meaning mainly the benzos.
The benzodiazepines had a dramatic impact on the practice of psychiatry. For the first time, psychiatrists were able to offer their patients a potent drug, like the mild Miltown, that did not sedate them. (The antipsychotics were simply too potent for routine use in psychiatry). The share of psychiatric patients receiving prescriptions increased from a quarter of all office visits in 1975 to fully one-half by 1990 (from 25.2 percent to 50.2) percent). With the benzodiazepines as the entering wedge, psychiatry became increasingly a specialty oriented to the provision of medication. With the profession’s main previous treatment modality, dynamic psychotherapy, now falling into disuse, an alternative lay at hand.
There was, however, one problem: The benzodiazepines turned out to be addictive, in the sense that patients’ symptoms after trying to discontinue the drug were often worse than before starting. In recognition of their potential for abuse, in 1975 the Food and Drug Administration put the benzodiazepines and meprobamate on its “Schedule IV,” controlling refills and imposing on pharmacists special reporting requirements. Sales had already leveled off, and by 1980 Valium (diazepam) stood number 32 on the list of most commonly prescribed drugs, Librium (chlordiazepoxide) number 59. It was the end of “Valiumania.” Nonetheless, the drugs had not exactly gone out of style: almost 7 million prescriptions a year continued to be written in the United states for Valium-like products.
Until this point, there had been very little “unscientific” in the narrative. The benzodiazepines were perfectly appropriate for the treatment of anxiety and mild depression, and science-schooled psychiatrists did well to put their patients on them Yet it had now become apparent that great sums were to earned in the sale of psychiatry drugs. As Valium soared in popularity, awareness dawned on drugmakers that here lay the markets of the future. As the highly competitive drug companies rushed into psychopharmaceuticals, they began to distort psychiatry’s own diagnostic sense. In trying to create for themselves market niches, drug companies would balloon illness categories. A given disorder might have been scarcely noticed until a drug company claimed to have a remedy for it, after which it became epidemic. As historian of psychopharmacology David Healy puts it, “ As often happens in medicine, the availability of treatment leads to an increase in recognition of the disorder that might benefit from that treatment.”
Take, for example, panic disorder. The tradition in psychiatry was to see panic as part of anxiety. As DSM-II said in 1968 of “anxiety neurosis,” “This neurosis is characterized by anxious over-concern extending to panic and frequently associated with somatic symptoms.” In 1964, however, Donald Klein, then at Hillside Hospital in Glen Oaks, New York, published an article suggesting that panic was really an illness entity distinct from anxiety. Partially funded by the Geigy and the Smith Kline and French drug companies, the study concluded that one could forestall such attacks by staying on medication. As Klein was a member of the DSM-Iii task force, as well as its subcommittee on “anxiety and dissociative disorders,” he was able to persuade other members of the correctness of his views. In 1980, with the publication of DSM-II, panic disorder became an illness of its own, characterized, it was said, by “the sudden onset of intense apprehension.” And marked by physical sensations such as sweating and faintness. The following year, in 1981, the Upjohn company of Kalamazoo, Michigan, marketed a new kind of benzodiazepine named alprazolam (Xanax), Because the market for benzos was sinking at the time, Upjohn attempted to reposition its benzo as a drug specific for the newly created disease entity “panic disorder.” In the 1980’s, the company funded extensive field trials—orchestrated by Cornell’s Gerald Klerman—to establish that panic was really an independent disease for which alprazolam worked wonders. The results were not entirely convincing. Nonetheless, by the early 1990’s, Xanax had become one of the hottest drugs in psychiatry, prescribed by many psychiatrists in good faith that they were practicing scientifically and that Xanax offered unique hope in the epidemic of panic disorder sweeping the nation. Among insiders, panic jokingly became known as the “Upjohn illness.”
Against this background of psychiatric diagnosis increasingly manipulated by pharmaceutical companies arose the psychiatry drug that was to become the household word of the 1990’s: Prozac. When Valium came along, both patients and their doctors were willing to define their problems in terms of anxiety once an effective drug existed for treating it. When Prozac, a drug for depression, arrived on the scene, the accent fell on depression as the hallmark of distress. “Our phone rings off the hook every time someone does a story about Prozac,” said one physician at Manhattan’s Beth Israel Medical Center. “People want to try it. If you tell them they’re not depressed, they say, ‘Sure I am!’”
…By 1993, qlmost half of all visits to American psychiatrists were for mood disorders. Just as Valium had assuaged a nation beset by anxiety, the availability of a new drug for depression had produced a pattern of disorder the drug was capable of treating.
What followed was a media psychocircus of suggestion, as Prozac and its competitors were extended to the world of the public as a panacea for coping with life’s problems even in the absence of psychiatric illness )one recalls that the great majority of individuals with a formal psychiatric illness seek no treatment of any kind). Prozac is “much more than a fad,” proclaimed Time in 1993. “It is a medical breakthrough” that has brought relief to individuals such as “Susan,” a self-described workaholic who becomes irritable around the time of her periods and once threw her wedding ring at her husband. Now the edges of her personality had been planed off a bit. It would be ludicrous to argue that such people suffered a formal psychiatric illness in the historic tradition of the agonized and the inconsolable, for real psychiatric disease cases terrible pain and disablement. Yet here lay part of Prozac’s core market.
Driven by the promise of problem-free personality and weight loss, Prozac took off more rapidly than any other psychiatric drug in history.
…Inserting Prozac into the history of psychiatry requires untangling good science from scientism. Good science lay behind the discovery of fluoxetine as a much safer and quicker second-generation antidepressant than imipramine and the other tricyclics…Scientism lay behind converting a whole host of human difficulties into the depression scale, and making all treatable with a wonder drug. This conversion was possible only because clinical psychiatry had enmeshed itself so massively in the corporate culture of the drug industry.
Aaron Kheriaty, "The Age of Prozac and the Triumph of the Therapeutic" (excerpt)
The history of antidepressant drugs is as old as time, for it begins with that ancient wonder and menace, alcohol. Opium, first popular in the 18 th century, alkaloids in the 19 th, and barbiturates at the turn of the 20 th all share similar disadvantages with their ancient precursor: addiction, sedation, and the inability to relieve core symptoms.
A major breakthrough came in 1955, with the release of meprobamate under the trade name Esquanil, called “Miltown” by the man who developed it. Almost immediately following its release, the demand for this “tranquilizer” far surpassed any other drug in the U.S.: pharmacists would put signs in their windows reading, “out of Miltown,” or “Miltown available tomorrow.” Librium, the first of the class of benzodiazepines, another medication for anxiety, became the number one prescription med in the U.S. during the 1960’s. In 1963, Valium, a more potent “benzo” was released; until the introduction of Prozac, Valium was the most successful med in pharmaceutical history, surpassing Librium as the number one selling American drug in 1969. These drugs caused enormous changes in the practice of psychiatry: the percentage of psychiatric patients receiving prescriptions increased from 25% to 50% between 1975 and 1990. According to historian Edward Shorter, “With benzodiazepines as the entering wedge, psychiatry became increasingly a specialty oriented toward the provision of medication.” But the balloon popped when benzos turned out to be addictive: patients’ symptoms after discontinuing the drugs were often worse than before starting.
Then came a new class of antidepressants, the SSRIs (selective serotonin re-uptake inhibitors). Shorter points out a curious shift of emphasis after the introduction of these medications: “When valium came along, both patients and their doctors were willing to define their problem in terms of anxiety once an effective drug existed for treating it. When Prozac, a drug for depression, arrived on the scene, the accent fell on depression as the hallmark of distress.” As one Manhattan psychiatrist exclaimed, “Our phone rings off the hook every time someone does a story about Prozac. People want to try it. If you tell them they’re not depressed they say, ‘Sure I am!’”
Many antidepressant drugs existed prior to Prozac and the other SSRIs, but these “MAO inhibitors” and “trycyclics” had poorly tolerated side effects, dangerous drug and food interactions, and were potentially lethal in overdose—a key consideration when prescribing to depressed patients who may be suicidal. Prozac, on the other hand, appeared to have relatively few side effects, negligible interactions with other drugs, and was safe in large overdose. What is more, it appeared to work. Approved by the FDA in 1987, Prozac was an unprecedented sensation. Shorter described it thus: “What followed was a media psychocircus of suggestion, as Prozac and its competitors were extended to the world public as a panacea for coping with life’s problems even in the absence of psychiatric illness.”TheNew York Times headlined, “With Millions Taking Prozac, A Legal Drug Culture Arises”; Newsweek proclaimed in 1994, “Prozac has attained the familiarity of Kleenex and the social status of spring water.”
The results were not an unalloyed good, as Shorter, usually a defender of the specialty, points out: “Psychiatry nurtured a popular culture of pharmacological hedonism, as millions of people who otherwise did not have a psychiatric disorder craved the new compounds because it lightened the burden of self-consciousness.” To borrow from the subtitle of his book, we are now living, for good or ill, in the “age of Prozac.” No medication has garnered as much attention from the popular press, or occasioned as much controversy among its detractors and defendants. A search on Amazon.com gives 62 recent books with “Prozac” in the title (contrast this with Viagra, which only had 35). This med has clearly elicited strong reactions from all quarters, as evidenced in some recent book titles, which range from the sublime to the absurd. Prozac is now a household name.
* * *
I wish now to situate our “age of Prozac” within the context of another contemporary phenomenon, dubbed “the triumph of the therapeutic” by sociologist Phillip Rieff in his classic 1967 study. According to Rieff, historically, “the West has attempted many successive transformations of the enemy, the world. It now chooses to move against its last enemy, the self, in an attempt to conquer it and assimilate it into the world as it is.” The result of this project is the recent emergence of what Rieff calls “psychological man”: a therapeutic character ideal, who replaces political man of ancient Greece, religious man of Christendom, and economic man of the nineteenth century.
In this age, in which technics is invading and conquering the last enemy—man’s inner life, the psyche itself—a suitable new character type has arrived on the scene: the psychological man.... He is anti-heroic, shrewd, carefully counting his satisfactions and dissatisfactions, studying unprofitable commitments as the sins most to be avoided.... Psychological man has constituted his own careful economy of the inner life.
Contrasting psychological man with his predecessors, Rieff says, “Western culture has been dominated by an ascetic modal personality.... For the culturally conservative image of the ascetic, enemy of his own needs, there has been substituted the image of the needy person, permanently engaged in the task of achieving a gorgeous variety of satisfactions.” Psychological man eschews contemplation in favor of action: he “understands morality as that which is conducive to increased activity. The important thing is to keep going.”
This sketchy outline of Rieff’s thesis, presented in broad strokes and sweeping generalizations, doubtless oversimplifies much; I expect objections. But who today can doubt its basic veracity? Consider the therapeutic culture that has emerged to meet the rising needs of psychological man. In the academy, for example, psychology has replaced philosophy as the highest human science, encompassing the others: we now have Freudian literary criticism, Jungian theology, Rogerian educational theory, Richard Rorty’s pragmatic “linguistic therapy” philosophy, an ethics of “universal emotivism,” evolutionary psychology, social psychology, and so on. James Schall, professor of political philosophy at Georgetown has noticed that in their writings his students’ most oft-used verb is “to feel,” which usually replaces “to think,” as in, “Plato feels that virtue is knowledge, but Aristotle feels that virtue is habit,” etc. In the popular culture, we have, of course, “pop-psychology”: reams of self-help books, encounter groups, est, primal scream therapy, and other fads. Not to be left in the dust, the state of California established a Task Force to Promote Self-Esteem. This is the triumph of the therapeutic.
Whether one judges these social changes to be signs of progress or regress (or some combination thereof) is immaterial to my purpose. Either way, the reality of this new cultural mentality is difficulty to deny. It forms the backdrop against which we must examine cosmetic psychopharmacology. The question relevant to our concerns is: what will this triumph of the therapeutic look like in our age of Prozac? The shift towards the therapeutic character type began with Freudian psychoanalysis; now that biological psychiatry has donned the therapeutic mantle, it appears psychological man may continue to pursue the same ends, using new and improved pharmacologic means.
This history relies on Edward Shorter’s popular, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. John Wiley & Sons, New York: 1997, pp. 314-325.
Ibid., 316.
Ibid., 319.
Ibid., 320.
Ibid., 323.
Cited in ibid., 324.
Ibid, 324.
I mention the following as illustrative examples: “Prozac Nation: Young and Depressed in America,” “Prozac Backlash,” “Prozac Diary,” “Talking Back to Prozac,” “Prozac: Panacea or Pandora?,” Beyond Prozac: Antidotes for Modern Times,” “Prozac Poet,” “Prozac Highway,” “Scorpio Men on Prozac,” “Prozac and Prosperity,” “Prozac Conspiracy,” “ Just How Smart is Prozac?,” “Cooking with Prozac: From Nuts to Soup,” “In Pursuit of Happiness: Better living from Plato to Prozac,” “Barking at Prozac, My Diary,” “Living with Prozac,” and my personal favorite, “Plato, Not Prozac: Applying Philosophy to Everyday Problems.”
Rieff, Philip, The Triumph of the Therapeutic: Uses of Faith After Freud (hereafter, Triumph). Harper & Row, New York: 1966. Cf. also the final chapter of his book, Freud: The Mind of the Moralist (hereafter, Mind). Doubleday Anchor Books, Garden City, New York: 1961.
Mind, chap. 5.
Ibid.
Triumph, 241.
Triumph, 41.
Cf. MacIntyre, Alasdair, After Virtue. UND Press, Notre Dame, IN: 1981.
Study Questions
- Consider the following sentence: “…patients began to view physicians as mere conduits to fabled new products rather than as counselors capable of using the doctor-patient relationship itself therapeutically.” How does this statement apply to primary care in the present day? Does the claim extend beyond the psychiatric drugs discussed in this essay to other ‘fabled products?’
- Consider the following statement. “As often happens in medicine, the availability of treatment leads to an increase in recognition of the disorder that might benefit from that treatment.” Is there a danger that the tail (treatments) will wag the dog (diagnosis)? Can you think of any present-day example of this phenomenon?
- What positive results could have come from the fact that millions of Americans started taking Prozac, with the ensuing development of a ‘legal drug culture’? Re-read the first paragraph of this essay to summarize the pros and cons of the development of this new cosmetic psychopharmacology.
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