The Antidepressant Era (review)

First synthesized in the early 1950s, antidepressants and antipsychotic drugs have helped to remake American psychiatry and cultural views of psychological distress. These therapies have been implicated in the dismantling of a vast network of state hospitals, the toppling of psychoanalysis by biopsychiatry, and the ambivalent cultural embrace of biological solutions for psychological distress, of which Prozac is emblematic. David Healy’s very important book charts a provocative and highly readable course through the history of psychoactive drugs.

A practicing psychiatrist, Healy is not opposed to either the use of psychotropic medications or a biologically informed understanding of psychiatric disorders. Nonetheless, he is highly “skeptical” of our current biopsychiatric world where disease and its cure are based upon a bacteriologic model in which there are specific treatments for specific diseases. Healy effectively and critically explores this socially made vision in his tale of how antidepressant medications, psychiatric clinical science, and an eager pharmaceutical industry helped to build this world.

The Antidepressant Era weaves together four interconnected histories. The first chronicles the discovery and development of antidepressant medications. Physicians in the 1950s fortuitously observed that a few newly minted compounds—namely imipramine and the monoamine oxidase inhibitors—elevated patients’ moods. Healy describes in detail this history, as well as subsequent events, such as the synthesis of Prozac and other similarly acting drugs.

The second narrative strand is about psychiatrists’ adoption and subsequent use of the randomized controlled trial (RCT) in assessing whether antidepressant and antipsychotic drugs worked. Healy argues that the RCT, now enshrined as the ultimate arbiter of valid clinical knowledge, decisively shaped how we understand psychiatric disease, reinforcing a bacteriologic conception of illness and its treatment. For Healy, the RCT was and is an uneasy mix of science and pharmaceutical interests attempting to comply with FDA regulations.

The third strand of the story describes the relationships between psychotropic agents and biological knowledge of psychiatric illness. In a complicated and iterative cycle, researchers attempted to understand the biochemical effects of psychotropic drugs, which in turn led to biological theories of psychiatric disease. These theories shaped research agendas that fed back to inform further investigations into how these drugs worked biochemically. Healy condenses this tangled history of often contradictory findings into a readable and highly useful summary.

Finally, The Antidepressant Era maps the recent history of how psychiatrists have remade the boundaries and content of diseases, largely in the image of biological psychiatry. While Healy would not deny that sad and depressed feelings are part of the human condition and undoubtedly have a biological basis, he argues that a confluence of social, professional, and pharmaceutical interests made depression into a discrete disease with a specific biological cure. He feels that drug companies have disproportionately influenced this process, not only by creating therapeutic interventions but also by largely determining what counts as disease. “Although there are clearly psychobiological inputs to many psychiatric disorders,” Healy writes, “we are at present in a state where companies can not only seek to find the key to the lock but can dictate a great deal of the shape of the lock to which a key must fit” (p. 212).

I have only a few reservations about the book. Healy occasionally lapses into an unnecessarily technical language and glosses over areas that deserve more explanation, which is especially the case in his analysis of randomized controlled trials. Many of his most controversial assertions, especially those concerning the relationship of the pharmaceutical industry to knowledge production, call for more detailed evidence in order to be wholly convincing. Despite these minor caveats, The Antidepressant Era is by far the most significant work written to date on the history of psychopharmacology. Healy raises extremely important questions that will no doubt stimulate further historical work. It is a book that should be read by clinicians, historians, and anyone curious about our scientific fascination with psychoactive drugs.