Pharmaceutical Reason: Knowledge and Value in Global Psychiatry (review)

Pharmaceutical Reason is an excellent and important ethnographic and historical study of the globalization of psychiatric expertise and psychopharmaceutical intervention. Andrew Lakoff explores how the diagnosis, science, and pharmaceutical treatments of bipolar disorder are received, contested, and utilized within various psychiatric communities in Buenos Aires, where a strong psychoanalytic tradition is largely in fundamental disagreement with the North American biomedical approaches that gave rise to the diagnostic category of bipolar disorder in the first place. In contrast to North American psychiatry, Argentinian psychiatry tends not to approach diagnoses in terms of epidemiological data or neuroscientific research. Rather, the psychoanalytic approach of Argentinian psychiatry emphasizes a given patient’s unique subjective experience, often in conscious opposition to biomedical models in which individual uniqueness is lost for the sake of diagnostic generalization and putative similarity to evidence- based medicine.

Lakoff ’s narrative begins as Genset, a French biotech company, pays a Buenos Aires hospital $100,000 for blood samples from patients with bipolar disorder. The company hopes to discover a genetic basis for the illness, but the hospital psychiatrists find themselves at a loss to identify patients with a diagnosis that has not yet penetrated Argentinian psychiatry. Lakoff then follows an ethnographic thread of doctors, patients, research scientists, and marketers, amply demonstrating how the globalization of psychiatric knowledge is at once a technical problem (how can transnational clinical populations be identified for comparable research?), a cultural problem (how do culturally specific understandings of mental illness get taken up and transformed across multiple cultural contexts?), and a social problem (how does transnational scientific knowledge about mental illness affect local social policy and social advocacy?).

Along the way, Lakoff explores how the very determination of the etiology and course of treatment for a given psychiatric patient can be a politicized process. He tells the history of salud mental, an Argentinian mental health reform movement begun in the 1960s, which was characterized by the political goal of social integration. Salud mental held that mental disease is not something to be located in an individual’s body, but rather that it originates socially, when an individual does not fit with his or her social environment. Psychoanalysis offered a philosophically consonant approach, since it emphasizes the individual patient as opposed to clinical populations, and it privileges subjective experience as opposed to epidemiological data. In Argentina, contemporary proponents of salud mental embrace psychoanalytic explanations of mental illness as a progressivist corrective to biological explanations (which are loathed as rationales for the disempowerment of individuals and social exclusion) and to the later editions of the DSM, the Diagnostic and Statistical Manual of Mental Disorders (which are politically suspect because of their perceived connections to American privatization of health through managed care and pharmaceutical marketing). At the same time, Lakoff explores how other hospital psychiatrists in Buenos Aires view the legacy of salud mental as a dangerous indifference to forms of biomedical reasoning that most effectively offer ameliorative pharmaceutical treatments to suffering patients. These psychiatrists often endorse biopsychiatry as a more pragmatic and flexible approach to mental health care.

Debates over how to identify and treat mental illnesses are part of the evolution of medical expertise and professional identity in Argentinian psychiatry. As Lakoff notes, many Argentinian psychiatrists are trying to position themselves as members of as global profession, thus needing to be receptive to dominant explanations of mental illness. On the other hand, Argentina boasts the largest per-capita number of psychoanalysts in the world, and the country’s psychiatrists have, on the whole, developed a unique professional identity that has been intimately caught up in national politics. At stake in the professional and political intricacies of Argentinian mental health care are fundamental cross-cultural questions about the “reality” of mental illness. As Lakoff puts it, the “thingness” of a mental illness like bipolar disorder is uniquely difficult to pin down. Not only is there no clear biological or genetic substrate for bipolar disorder, but “seeing” bipolar symptoms in the first...