- Historic Sites
How Prozac Slew Freud
In the past hundred years psychiatry has come full circle: Psychoanalysis lost; medicine won
September 1998 | Volume 49, Issue 5
By 1956, two years after the American launch of chlorpromazine, Life was headlining NEW AVENUES INTO SICK MINDS . The story compared noise levels in a disturbed ward before and after the introduction of chlorpromazine. Before, the ward had been 220 times louder. With chlorpromazine began the takeoff of psychopharmacology, the branch of biological psychiatry that deals with medication. Chlorpromazine’s success initiated the search for other kinds of psychiatric drugs and for insight into the mechanisms of their action in the brain.
Thorazine’s obvious effectiveness gave it the same persuasive punch as penicillin and initiated the search for other kinds of psychiatric drugs.
Chlorpromazine did not represent the first use of drugs in psychiatry. The French novelist Marcel Proust, for example, was dependent upon barbiturates, the heavy-duty sedatives that preceded Valium. Virginia Woolf often took Veronal, a brand-name barbiturate. In asylums powerful laxatives like castor oil had once been commonly given for schizophrenia. But with chlorpromazine, one had a drug that made a difference.
Psychoanalysts were, in the main, hostile to the discovery. They struggled to find psychoanalytic explanations for chlorpromazine’s success (”protects patients from overwhelming sexual and aggressive impulses,” went one), and the principal American psychiatric journals, dominated by analysts, refused to accept articles on psychopharmacology.
This was in the mid-1950s. At the time there was a second highly successful treatment for mental illness that later would be buried under adverse publicity. Even today many readers will react negatively when they hear about electroshock, or electroconvulsive therapy (ECT). First developed in 1938, ECT had by the mid-1950s been refined to the point at which it was accepted as a normal therapy in the treatment of depression and psychosis. Why shocking the brain to the extent of eliciting convulsions makes psychotic patients better remains unclear. Yet empirically the therapy has proved itself. ECT is, in fact, at present the single most effective treatment for major depression, particularly in cases where drug therapy has failed or is inadvisable. It has prevented many severely depressed people from committing suicide in the depths of their despair.
However, in the 1960s a generation in revolt against technological solutions to problems they thought should be handled by kindness and community action decided that ECT brutalized and dehumanized patients. Ken Kesey, a creative-writing student who had been an orderly at a psychiatric hospital in California, produced in 1962 the acetylene flame with which the sixties Zeitgeist burned away ECT: the novel One Flew Over the Cuckoo’s Nest . Kesey had acquired the idea that ECT “fried” the brain. When, in 1975, Milos Forman made the book into a movie, it became United Artists’ biggest-ever hit at the time and helped persuade an entire generation that ECT belonged in the chamber of psychiatric horrors alongside lobotomy. For the next decade or so, ECT virtually vanished from the armamentarium of useful psychiatric therapies.
Thanks to the work of a small group led by Max Fink, of the State University of New York at Stony Brook, electroshock has recently returned to favor. Its rehabilitation is testimony to the power of science in medicine: The ECT advocates were able to show that it really did bring people back from depression, and rapidly too, without the three-week wait often required for antidepressants to kick in and with very few side effects, the much-trumpeted risk of permanent memory loss having been greatly exaggerated.
Despite the loss of ECT in the 1960s, the revolution in psychiatry continued on, almost entirely drug-oriented. Chlorpromazine opened the way for a cornucopia of medications that could help major psychiatric illnesses. Of course, all that spilled from the cornucopia was not bounty. Some were me-too drugs, thrown onto the market only for competitive reasons; others were identified as toxic and soon withdrawn; still others lapped from psychiatry into the streets as drugs of abuse. Yet on the whole these medications greatly ameliorated the lot of people with mental illness.
But what of those millions and millions who suffered lesser but still painful woes: depression, anxiety, agoraphobia? The story of what one of its most effective proselytizers—Peter Kramer of Brown University, who championed the drug Prozac—called “cosmetic pharmacology” began with a Czech-born Jewish refugee from Hitler named Frank Berger. Although trained as a bacteriologist, Berger wrote, “I was interested in the neuropharmacological basis of mental disturbances. Most people get nervous and irritable for no good reason. They flare up, do not differentiate between serious problems and inconsequential ones, and somehow manage to get excited needlessly. These people are not insane; they are simply overexcitable and irritable, and create crisis situations over things that are unimportant.”