Methods and madness: Severe mental illness in the age of psychopharmacology
Joel Braslow
UCLA
From the synthesis of chlorpromazine in 1950 (marketed in Europe as Largactil and in the U.S. as Thorazine) to the present-day mass marketing of drugs like Prozac, Zoloft, and Paxil, the psychopharmacological revolution has fundamentally altered how we understand and treat psychological distress. These past fifty years have witnessed the dismantling of an enormous state hospital system (housing at its peak over a half a million patients), the eclipse of psychoanalysis and psychodynamic psychiatry by biological psychiatry, the creation of a multibillion dollar psychopharmaceutical industry dependent upon particular views of psychological distress and its cure, and biological psychiatry’s infiltration of nearly every nook and cranny of how we experience and define ourselves. Despite these profound changes in our understanding of psychological ills, we know little about how the psychopharmacological revolution has altered the everyday job of psychiatrists caring for those most severely afflicted with psychiatric illness. Specifically, how did these new technologies alter what psychiatrists deemed as psychiatric disease, indications for treatment, and what they saw as successful outcomes? The aim of this paper will be to address these questions by way examining everyday clinical practices from the 1940s to the present. Looking primarily at patient records from several publicly funded California hospitals, I will focus on the ways in which psychopharmacologic practices reshaped the meaning of the social and the biological in how physicians (and patients to a lesser extent) understood illness and therapeutics.
Psychopharmacology in the age of anxiety: The Miltown revolution in historical context
Andrea Tone
McGill University
This paper will explore the development, phenomenal profitability, and cultural currency of meprobamate (sold as Miltown and Equanil), the first of the so-called minor tranquilizers. Developed in 1950 and approved by the Food and Drug Administration in 1955, the prescription-only tranquilizer quickly became a commercial sensation, the first psychotropic wonder drug in American medical history. Drawing on a range of historical documents, including archival manuscripts, FDA manufacturers’ files, court cases, medical reports, and oral histories, this presentation will locate this critical chapter in the creation of psychopharmacology in a framework attentive to the importance of historical context. It will suggest that that the Miltown Revolution, which had lasting repercussions for the development and medical diffusion of drugs to treat outpatient psychiatric disorders, was not only a medical story involving mental illness and health, but also one inseparable from politics, economics, and consumer culture.
Gender stereotypes in the diagnosis of depression: Systematic content analysis of medical records
Jonathan Metzl
University of Michigan
A growing body of literature describes medicalization as a process whereby pharmaceuticals become treatments for everyday problems and concerns. However, few studies have applied cultural trends in psychopharmacology to actual clinical material. This project addresses this issue so by exploring whether criteria outside of the Diagnostic and Statistical Manual have been used as indicators for treatment of dysthymic or depressive disorders over the course of the U.S. SSRI phenomenon. Systematic content analysis was performed on randomly drawn medical records of 160 adult patients diagnosed with depressive disorder on initial visit to the University of Michigan Department of Psychiatry from the years 1985, 1990, 1995, and 2000. This analysis was also performed on two randomly selected control groups: the records of 70 psychiatric patients whose primary diagnosis was one other than depression, and of 40 non-depressed medical patients seen in the UM internal medicine clinics, both from the same time periods. The percentage of charts exhibiting certain characteristics (DSM versus non-DSM language) across four time periods was calculated using Fisher’s Exact Test for two-way contingency tables. We found that middle-aged women’s problems with marriage, motherhood, and menstruation (but not work) became increasingly associated with depressive illness. Aggression, hostility, and athleticism were progressively deemed symptoms in middle-aged men. Such findings suggest that psychiatrists clearly used professional tools such as the DSM in the act of generating the medical record, but their observations seem also to have taken account of a shifting set of cultural expectations and norms. The presentation concludes by suggesting that, in an age of mass-marketing, clinicians of all specialties need become competent in recognizing how cultural assumptions can shape understandings of mental illness and its treatments.
Cargo cult science: On the interaction between evidence, medicine, & commerce
David Healy
Cardiff University
This paper considers the evidence from randomised controlled trials of psychotropic agents as recently applied to the practice of psychiatry/medicine. It illustrates how one interpretation of clinical trial data and statistics, which takes data of marginal significance as evidence of treatment efficacy, is currently dominant, and why this is arguably not the correct interpretation and definitely not the only possible interpretation. An alternate interpretation points to treatment effects rather than efficacy. The consequences of the dominant interpretation for academic journals, drug development, patient treatment, and globalisation are drawn out, culminating in a descriptions of the processes of guideline capture, brand fascism, and informational reductionism. The paper questions whether science can be expected to necessarily bring about a global homogenisation or whether what is being globalized at present is simply bad science.
Partial truths and competing paradigms: Stakes in the administration of drug compliance in the treatment of ADHD
Kalman Applbaum & Michael Oldani
University of Wisconsin
Patient compliance (or adherence) to medication is a key focus of practical research in health services. Most research has focused on patient behavioral tendencies and on the provider-patient relationship. In mental healthcare in particular, where noncompliance is seen as both a contributing cause and effect of illness, strategies to improve compliance have met with unsatisfactory success. The current research identifies various provider-stakeholders—physicians, schools, family groups, HMOs, insurers, the criminal justice system, pharmaceutical companies, etc.—as well as patients, aiming to incorporate an analysis of their interests, working models and assumptions into the reevaluation of mainstream compliance/adherence paradigms. It will demonstrate how stakeholder-providers construct their relationships toward clients (patients, end users) equally in keeping with internal significances (or “theories of practice”) and audit requirements. The paper presents case material pertaining to the use of psychoactive drugs in the treatment of childhood ADHD, and secondarily to the use of anti-psychotics in the management of the varied symptoms of schizophrenia.
Pills that swallow policy: India’s National Mental Health Program
Sumeet Jain & Sushrut Jadhav
University College London
India’s National Mental Health Program (NMHP) was initiated in 1982 with objectives of promoting community participation and accessible mental health services. A key component involves Central government calculation and funding for psycho-tropic medication. Based on ethnography of a community psychiatry program in north India, this paper traces the biosocial journey of psycho-tropic pills from the centre to the periphery. As the pill journeys from the Ministry of Health to the clinic, its symbolic meaning transforms from an emphasis on accessibility and participation to administration of ‘treatment’. At its final destination of delivery in the rural health centre, the pill becomes central to professional monologues on compliance that mute the voices of patients and families. Additionally, popular perceptions of government medication as weak and unreliable create an ambivalent public attitude towards psychiatric services. Instead of embodying participation and access, the pill achieves the opposite: silencing community voices, re-enforcing existing barriers to care, and promoting chemical solutions to social issues. The symbolic inscription of NMHP policies on the pill fails because these are contested by more powerful meanings generated from local social and cultural contexts. This understanding is central for development of policy that can effectively address local needs in rural India.
Ways of distributing psychopharmaceuticals in India: The case of fluoxetine (Prozac)
Stefan Ecks
University of Edinburgh
What role do networks of distribution play in the widening use of psychopharmaceuticals around the world? To date, the social effects of psychopharmaceuticals have mostly been studied on four levels: marketing strategies of companies, psychiatric diagnostics, prescription practices, and popular/patient understandings of drugs. The ways in which medications are distributed have never been studied in detail. In comparison to established topics of research, drug distribution appears to be rather less intriguing. Distribution seems to be something purely technical, a mundane job that needs to be done with any commodity: inventories, storage, shipping, taxes, and so forth. Yet psychotropic drugs are a special kind of commodity, and the precise ways in which they are distributed has tremendous effects on all parts of the chain, including how doctors prescribe them and patients use them. The paper will present initial findings from the collaborative project “Tracing Pharmaceuticals in South Asia” on the distribution networks around fluoxetine (Prozac) in India.
Psychotropic medication use with children and adolescents: A comparative study
V. Kovess & C. Sevilla Dedieu
Fondation MGEN
Use of psychotropic drugs varies across the diverse EU countries, with some being high users such as France, Italy, Spain and Belgium, whereas Germany and the Netherlands are low users. These differences may be partially explained by cultural factors such as use of herbal remedies in Germany and by features of the health care systems such as the tendency in France for GP’s to conclude a consultation by giving a prescription, whereas Dutch GPs tend to conclude by giving advice. The place given to psychotherapies and alternative medicines play an important role as well. In this presentation, we will contrast the trends for adults with those concerning children and adolescents. In some countries like France, where psychotropic drug use is the highest in EU, some psychotropic medications for children have an extremely low rate of use due to strong constraints on treatment initiation, while this does not exist for other psychotropic drugs. These restrictions can be explained by the psychoanalytic influence in the child psychiatric domain, which was able to support these restrictions. We will present data on a sample of approximately 7000 children and adolescents from a French HMO (MGEN) showing that psychotropic drugs use increases dramatically after 15 years; males outnumbered females in the youngest ages, and then this tendency reverses. Most prescriptions for adults are written by GPs and quite a few prescriptions do not conform to the prescription restrictions for adults. although this concerns mainly the adolescents. These results will be compared to the situation in the Netherlands, which has the best documentation concerning child psychotropic prescriptions, where an increase of prescriptions for stimulants has been observed. In the Netherlands, the health care system is oriented toward a non-medical model delivering a message on tolerance toward symptoms and access to non-medical mental health care is part of the health care system. The discussion will show how the use of psychotropic drugs for child psychiatric disorders in the diverse EU countries is shaped by how theoretical models, health care system organisation, and especially the place given to non medical providers together with cultural background.
Edgy ethics and storied science: Marketing neuroscience as the truth of depression
Nathan Greenslit
Massachusetts Institute of Technology
My paper explores how, in the face of increasingly intense public cynicism about the pharmaceutical industry, drug marketers carve out their own ethical niche from which they innovate on ways to persuade U.S. consumer audiences with scientific facts that double as public relations. Drawing off of ethnographic encounters with marketers, consumer-patients, and psychodynamic psychiatrists I present a thick description of how individuals encounter and incorporate the putative neuroscience of direct-to-consumer advertising to negotiate their personal knowledge of depression and anxiety, and to manage their identity, everyday practices, and professional pursuits.
Ethnic medication: Towards a new scientific racism?
Sylvaine De Plaen
Hôpital Sainte-Justine
As a clinician with training in anthropology, who works with patients from diverse cultural backgrounds, I have always been interested in looking at the interplay of culture and psychopathology in the daily clinical setting. The development of new domains of knowledge in psychiatry, such as ethnopsychopharmacology, is encouraging because it reflects a new sensitivity to the role of culture in the way people respond to treatment and medication. But such a development also raises important ethical issues by offering new legitimation to categorizations of people according to their origin and (often) their skin color. In the United States, the recent release of a new antihypertensive medication marketed specifically for “blacks”, Bidil, brings back this issue of race in the scientific domain. Are there any consequences in that revival of old physical stamps to categorize people and define their needs and identity? Does cultural psychiatry have a special responsibility in considering new forms of racism legitimated by contemporary scientific discourse? This presentation will try to address this crucial issue for transcultural psychiatry today.
Therapeutic reasoning and the rationales underlying day-to-day psychotropic prescribing practices: Back to 19th-century therapeutic relativism?
Johanne Collin
Université de Montréal
Some time ago, Géza Roheim called attention to a key Western characteristic: slowly evolving societies have become rapidly changing societies, a phenomenon he designated‚ long before it had gained currency‚ as “therapeutically oriented societies.” In these societies, characterized by the demand that individuals continually strive to adapt, psychiatric and psychopharmacological interventions play a major role in the processes of socialization and the management of social stresses. As the use of psychiatric medications in Western societies has continued its dramatic rise, much has been written about the major role played by pharmaceutical companies in shaping social and cultural attitudes toward medication. Less attention, however, has been paid to therapeutic reasoning and the rationales underlying the day-to-day prescribing practices of physicians. Based on an analysis of medical and psychiatric journals and in-depth interviews with GPs, this paper aims to shed light on three major trends in the prescription of psychotropics (mainly for children and older people): a) the tendency to dissociate psychotropic prescribing from the diagnosis of mental disorder; b) the growing complexity associated with polyprescription and multimodal treatments; and c) the tendency to move from a primary-illness approach to a target-symptom approach, which has paved the way toward relativism in therapeutic strategies.
Tense prescriptions: Doctors’ knowledge and doubts regarding Alzheimer medications in Brazil
Annette Leibing
Université de Montréal
Alzheimer’s disease emerged as a medical category in urban Brazil in the 1990s. From the beginning it was considered a disease requiring the attention of neurological, psychiatric, and geriatric expertise. Additionally, more peripheral “multidisciplinary” interventions (psychological, social, etc.) have been emphasized as important to the patient’s well-being. The most important tools for all interventions are medications although, as elsewhere, the effectiveness of these medications has been questioned since their inception. How do doctors prescribe this kind of medication within a context of uncertainty? Relying on interviews with health professionals in Brazil, participant observation in a psychogeriatric unit, and document analysis, this paper analyzes the historical dimension of the use of these medications in Brazil, and presents Alzheimer medications as glocal “technologies of hope”.
Scripting control: Aboriginal and mainstream Canadian understandings of phamily life
Michael J. Oldani
University of Wisconsin, Whitewater
This paper examines the use of psychoactive medication as a mechanism of individual, familial, and social control. Ethnographic cases are drawn and presented from fieldwork conducted in Winnipeg, Manitoba, (2000-2002). Part One of this paper will outline how pharmaceutical prescriptions for mental/behavioral health are employed by parents to improve the mental health of their children while simultaneously mirroring deeply embedded cultural scripts. What these pharmaceutical families, or phamilies, mean for various stakeholders – parents, the pharmaceutical industry, high-prescribing doctors – will then be critically assessed. Part Two will show how rural doctors in western Canada incorporate a racialized geography into their (high) prescribing logic for treating Aboriginal children with complex behavioral disorders, namely FASD. The prescribing practices of doctors and school officials have forced some Aboriginal parents to reject psychoactive medication as a treatment option for their children’s behavioral condition. One such case of resistance will be discussed. In particular, this case will allow for a closer examination of the various (post)colonial scripts that are being incorporated (and repeated) through the current logic of psycho-pharmaceutical prescribing. Taken together, these cases provide an opportunity to reexamine Mattingly’s notion of “clinical and therapeutic plots.” This paper will argue that pharmaceutical scripts (both drug prescriptions and emplotted dramas) continue to structure both real and imagined forms of ph/family life and personhood.
Uncertainty in an era of evidence-based practices: The ambiguous texture of medicines on a transcultural clinical scene
Ellen Corin, Cécile Rousseau, & Annie Gauthier
McGill University
For decades, the medicalisation of personal and social problems has been a popular object of study for social scientists. The current salience of pharmaceuticals in critical social sciences research can be seen as an offshoot of that line of research, which also reflects the ethos of consumerism dominating Western societies. The concreteness of pharmaceuticals also gives a feeling of mastery over the elusive dimension of mental health problems, particularly in the case of psychosis, and delineates a perimeter of cure easily amenable to standardization. This is in line with the current value attached to “standard”, a notion that Petryna and Kleinman consider as an important social and cultural marker of modernity. This concreteness also constitutes medicines as a privileged healing tool fitting with the current hegemony of evidence-based practices. As a kind of counterpoint to this vision of medication, narratives collected in the context of research on the place of culture on the clinical scene in the case of early psychosis reveal the high degree of uncertainty that permeates discourses and practices associated with medication, for practitioners as well as for patients and significant others. Forty patients from 5 cultural origins (Afro-Caribbean, South Asian, Latino-American, Franco-Quebecois, Anglo-Quebecois), a significant other, and their practitioner were interviewed with the Turning Point/Period Interview, a qualitative grid aimed at reconstructing the perceived history of signs, coping, explanations, reactions, and help-seeking. Re-interviews were done after one year. This paper will focus on the place of medication in the negotiation of meaning and practices, and on the personal and social significance and import of “certainty” and “uncertainty” in that context. It will also examine the way negotiations about medication act to delineate a privileged space of exchange and discuss its implications in regard to the human dimension of healing in contemporary practices.
Psychological ramifications of psychiatric medication in university students
Norman Hoffman
McGill University
There has been a dramatic increase over the past ten years in the percentage of college students taking prescription psychotropic medication. Studies have indicated that from 12 to 25% of college students are on psychiatric medication. While some people have suggested that this is due to improved treatments that allow students with psychiatric disorders to reach university, there is little evidence to support this claim. Clinical experience at the McGill Mental Health Service has indicated that the rise in psychological difficulties in university students may, in part, be due to an inappropriate use of diagnosis and medication in pre-university students. The labeling of adolescents as having a “chemical imbalance” can interfere with emotional development, and encourage both the adolescent and the family to avoid dealing with underlying emotional issues. From a clinical perspective, modern anti-depressant medications appear to be primarily mood dampeners, leading to short-term amelioration of intense affect but often with negative psychological effects. There are also indications that medication can interfere with the efficacy of psychotherapy. These issues will be highlighted through the use of clinical case studies.
Selfhood, psychopharmaceuticals and society: Narratives of psychotropic medication use among adolescents, their parents, and physicians
Kelly A. McKinney
McGill University
Since the early 1990s, the number of adolescents and children as young as 2 years old taking psychiatric medications including (methylphenidate) Ritalin, (fluoxetine) Prozac and other selective serotonin reuptake inhibitors (SSRI’s), anti-psychotics, and mood stabilizers has dramatically increased in North America. Most of these medications have not been approved for use with pediatric populations and are prescribed off-label, despite concerns about the potential but unknown effects these agents may have on childrens’ overall growth and development, as well as evidence indicating that children react differently to these medications than adults, and that the risk-benefit ratio for children and adolescents may vary widely across different medications. Based on a study currently taking place in Montreal, this paper will examine the role and meanings of these medications for adolescents, their parents, and prescribing physicians at an adolescent health clinic.
Adolescent experience of psychotropic treatment
Jerry Floersch
Case Western Reserve University
The aim of this qualitative study is to broadly describe how adolescents experience psychotropic treatment. Using an open-end, semi-structured survey instrument, respondents, ages 12 to 17 years, diagnosed with one or more psychiatric disorders, and who were currently prescribed psychiatric medications, were queried about their medication and treatment experience. Data were analyzed using grounded theory techniques. Twenty adolescents with a mean age of 14.75 years, with mood (15\20), behavioral (3\20), psychotic (1\20), and eating (1\20) disorders and with a mean of 2.35 prescribed psychiatric medications were enrolled in the study. They reported experiencing medications through body, emotion, cognition, behavior, self, diagnosis/disorder, and expectation/hope dimensions. As well, parents influenced adolescent perceptions of the illness and of the need for medication. It appears that the adolescent experiences psychopharmacotherapy through distinct subjective and intersubjective dimensions. Treatment experience might be improved if practitioners included in their medication treatment the adolescent’s personal understandings of the illness, their perceptions of how medications work, and a discussion of how medications are daily managed.
The tenuous notion of specificity
Amir Raz
McGill University
Modern medicine is based on the ideal of specific diseases, and specificity has revolutionized thinking in clinical practice (e.g., psychiatry) as well as biomedical research (e.g., neuroscience). Different notions of specificity exist (e.g., clinical, biological, and behavioral). Behavioral specificity takes on new meaning in light of recent neuroimaging and genetic findings. Drawing on the metaphor of pharmacological specificity, we provide converging data suggesting that at least for certain individuals, specific behavioral interventions can influence focal brain activations. Interpretation of these data suggests strategies for studying the neural basis of suggestion and placebo response, and holds promise for the optimal matching of patient and treatment.
Papers presented at the ASI 2007 will be collected in a special edition of Transcultural Psychiatry.