Book Review

The Antidepressant Era

N Engl J Med 1998; 338:1475-1476May 14, 1998

Article

The Antidepressant Era
By David Healy. 317 pp. Cambridge, Mass., Harvard University Press, 1997. $39.95. ISBN: 0-674-03957-2

Major depression is increasingly recognized as a worldwide cause of morbidity, mortality, and health expenditure. A study by the World Health Organization and Harvard University estimates that major depression is currently the fourth leading cause of disability worldwide. An epidemiologic study of more than 40,000 people found consistent core symptoms and a youthful age at onset in 10 diverse countries. A committee of geneticists convened in 1997 by the National Institute of Mental Health (NIMH) concluded that there was sufficient evidence of a genetic basis to support funding large-scale molecular studies of early-onset major depression. Yet David Healy's scholarly and provocative review of the antidepressant era concludes that “the discovery of antidepressants has been the invention of and marketing of depression.” Ignoring 35 years of NIMH-funded research on the epidemiology, familial risk, clinical course, and treatment of depression, Healy gives the credit for the use of antidepressants to the marketing departments of pharmaceutical companies, fueled by the regulatory mechanisms put in place in the 1960s with the expansion of the Food and Drug Administration (FDA). The FDA, the medical profession, and the pharmaceutical industry, he notes, signed onto a bacteriologic model of disease, with antidepressants considered a specific drug for a specific disorder, whereas Healy suggests that antidepressants treat a range of nonspecific symptoms that lie along a continuum. As he says, “My own views on depression . . . lie sufficiently outside the mainstream.”

Healy's solutions include increasing the sensitivity of physicians to the social factors leading to illness and consultation; weakening the corporate hold on pharmaceuticals by retaining new drugs on prescription status for a limited time (three to five years) or selling them over the counter; helping the medical profession to rediscover its own therapeutic skills instead of relying on specific agents; and finally, introducing personal narratives into medical therapeutics. These moves, he feels, will counteract the psychopharmacologists and neuroscientists who have chased “the question of `how' even if the idea of a soul appears to be banished in the process.”

The Antidepressant Era is not a run-of-the-mill history of medication, though it can serve that purpose. The lessons drawn from it by many readers, however, may be quite different from those drawn by Healy. As a history, the book is brilliant and brilliantly written, tracing the introduction of antidepressants, which, along with the first antibiotics and antihypertensives, created a therapeutic revolution just after World War II. These developments brought health to the center of global politics and created the possibility of a common language that crossed ethnic, race, and class barriers. The paths traced begin in antiquity. Healy discusses concepts of disease and illness beginning with Hippocrates; the isolation of the tubercle bacillus by Robert Koch; the beginning of the pharmaceutical companies (in 1804, 90 patent medicines were listed; by 1857, the list had grown to 1500); the discovery of the power of marketing with aspirin; the 1951 act that gave the FDA power to decide which medicines should be made available by prescription; and the 1962 Kefauver–Harris amendment, which charged the FDA with establishing the efficacy of over-the-counter as well as prescription drugs. The role of the NIMH in testing the new psychotropic drugs, the discovery and testing of antidepressants, and the science developed to facilitate testing are well described. Since many of the scientists who participated in the antidepressant revolution were still around to be interviewed for this book, the material is vivid and personal.

Healy's “nuts-and-berries” approach to human suffering is appealing except when applied to some real patients. This issue comes to a climax in the final chapter on the Osheroff legal case, in which my late husband, Gerald L. Klerman, M.D. (a developer of psychotherapy and an expert in treatment evaluation), argued that a patient had the right to receive treatments that had been demonstrated to be effective for his or her condition. Osheroff's serious psychotic depression had resulted in his hospitalization and damage to his personal life and had not responded to psychotherapy alone. The empirical evidence, Klerman argued, pointed to treatment with antidepressants, with or without psychotherapy, rather than long-term psychoanalytic psychotherapy alone, which had not been demonstrated to be effective for psychotic depression and had not been effective in this case. The details of the debate with Alan A. Stone, M.D., the Harvard professor who argued that Klerman's view was an inappropriate indictment of psychoanalytic psychiatry, are chronicled by Healy. This debate took place in 1990; Klerman died in 1992. Not described in Healy's book is the 1995 keynote address to the American Academy of Psychoanalysis in which Stone appeared to have changed his views. He stated that psychoanalysis is “an art form that belongs to the humanities and not to the sciences.” In reference to the use of narratives as therapeutics he stated that “based on the scientific evidence now available to us, the basic premises may all be incorrect.”

Healy's book misses the paradox of antidepressants. In fact, we use both too much and too little antidepressant treatment. (This is also true for psychotherapy.) The marketing success of these drugs may have led to overuse for minor problems of daily life. But a host of epidemiologic studies show that most people with major depression have not had their condition diagnosed, and even many of those with a diagnosis remain untreated. Preoccupied with the dynamics of overprescribing, Healy ignores the public health consequences of the larger failure to use safe and effective antidepressants that can reduce suffering and even save lives.

By all means, buy and read Healy's book. He notes, “There are . . . aspects of the antidepressant story that have forced skepticism on me.” The reader might feel the same about his interpretations.

Myrna M. Weissman, Ph.D.
College of Physicians and Surgeons, Columbia University, New York, NY 10032

Citing Articles (1)

Citing Articles

1. 1

   Michael Robertson. (2005) Power and knowledge in psychiatry and the troubling case of Dr Osheroff. Australasian Psychiatry 13:4, 343-350
   CrossRef