Antidepressant Era Anderson

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Psychological Medicine, 1999, 29, 1003–1008.

Printed in the United Kingdom


# 1999 Cambridge University Press

Book reviews
The Antidepressant Era. By D. Healy. (Pp. 317 ; marketing of depression itself so that we now
£26.50.) Harvard University Press : consider it a major health priority. It is truly
Cambridge, MA. 1997. astonishing today to have pointed out that
Antidepressant Therapy at the Dawn of the Third ‘ depression ’ was a rare condition in the 1950s
Millennium. Edited by M. Briley and S. A. with initial doubt about the commercial sense in
Montgomery. (Pp. 350 ; £39.95.) Martin putting money into developing a treatment so
Dunitz : London. 1998. unlikely to pay back the investment. Was
depression manufactured or discovered ? What
In The Antidepressant Era David Healy charts do we make of the proliferation of diagnoses
the history of antidepressant drugs with an from 180 in DSM-II to over 350 in DSM-IV ?
emphasis on the personalities involved and social These questions are relevant to understanding
factors. He describes present views about de- the present psychiatric market place with the
pression and its treatment in the light of the ‘ discovery ’ that previously overlooked disorders
development of antidepressants and raises (e.g. social phobia) are really very common and
questions, not only about the role of phar- require doctors to be more active in their
macological specificity in the treatment of identification and treatment. Posing this ques-
psychiatric disorders, but also about the status tion naturally leads to polarized answers. On the
of diagnosis itself. He is arguably one of the best one hand it is argued that now we have specific
placed people to tackle this task given his own treatments for carefully identified disorders it is
experience in psychopharmacology and his wide negligent to withhold treatment proven to be
range of interviews with pioneering psycho- effective (see the discussion of the Osheroff case
pharmacologists. in the book). On the other hand, many outside
There is a fascinating story to be told and he the orthodoxy of medicine believe in a com-
has a unique insight into the drama behind the mercially driven conspiracy to develop markets
dry bones of the authorized version that appears for new drugs (aided and abetted by Regulatory
in standard psychopharmacology textbooks. Authorities) leading to a medicalization of
Although the title implies a focus on the last 50 distress, which ultimately results in more prob-
years of drug treatment, Healy paints on a much lems and unhappiness than it solves.
broader canvas taking what might be called Healy walks a line between the extremes. He
the ‘ pre-history ’ of psychopharmacology and makes the vital point that the development of
putting this into the wider social and medical antidepressants in particular, and psychotropic
context including the development of Psychiatry drugs in general, must be viewed in parallel with
as a discipline in the twentieth century. There is changes in society and cannot simply be seen as
a complex interweaving of themes in the book, a story of disinterested scientific progress. In the
which include the development of current end, however, we are left a little uncertain as to
concepts of illness and disease, the emergence of his own position on the matter ; indeed whether
the idea of organ-specific disease and targeted the issue is capable of any straightforward
treatment (‘ magic bullets ’), the history of resolution is very much in doubt. As he points
Pharmaceutical Companies with their roots in out, if the story of psychopharmacology had
patent medicines and organic chemistry, govern- been different we could be surveying a very
ment regulations increasingly moulding the different psychiatric landscape, but not necess-
direction of research, the rise in neuroscience, arily a better one.
the development of current diagnostic systems The value of this book then is more in the
and research methodology and, last but not questions it raises rather than the answers it
least, medico-legal pressures. provides. There will be many who do not accept
Central to the story of antidepressants was the aspects of his formulation (for example that
1003
1004 Book reviews

many current antidepressants may be better central feature. The three chapters that explore
considered as psychic energizers or ‘ tonics ’) or the human biological aspects are likely to be
his solution (deregulating medicines, partially or recognized by many readers, Delgado et al. and
fully, and empowering people). I cannot do monoamine depletion, Linnoila et al. and 5-HT
justice to the scope of his book in this review but and impulsivity, Cowen and 5-HT challenge
that very scope also leads to an interpenetration tests. These chapters provide brief up-to-date
of themes that left me confused at times. There summaries of the authors’ studies. The remaining
were also the inevitable minor irritations in- nine chapters include fairly standard reviews
cluding an unsettling wavering between a ranging from the epidemiology of depression
European and United States perspective and (Angst) to treating resistant depression (van
some minor factual inaccuracies (e.g. fluvox- Knorring & Bingefors) via adjunctive treatment
amine is not the most potent 5-HT reuptake (Blier et al.) and suicide prevention (Mequies et
inhibitor). al.). I was interested in non-pharmacological
Overall, I would highly recommend this book, physical treatments (Kasper & Neumeister) but
which should be required reading for those disappointed that neither ECT nor transcranial
involved in researching, developing, prescribing magnetic stimulation were discussed.
or regulating psychotropic drugs. How to sum up the book ? There is much
In contrast Antidepressant Therapy at the useful information between the covers but I was
Dawn of the Third Millennium, edited by Mike left uncertain as to its ultimate purpose and
Briley and Stuart Montgomery, is very much a focus. Overlap between chapters occurs, but is
statement of orthodox thinking that ‘ sets out to not excessive, and a good flavour of some of the
present an overview of the current and near main current issues and directions of research is
future advances in antidepressant therapy ’. It is imparted. In the end, however, it is not com-
a multi-author book that follows the familiar prehensive or rounded enough for the general
format of a series of independent chapters psychiatric reader, or yet novel or detailed
written by experts who, in general, outline their enough for the expert. It is a useful source for
own research on a particular topic. summaries of prevalent theories, and I have no
Ten of the 19 chapters discuss biological doubt that I will use it as such, but I hesitate to
mechanisms involved in depression and its give it a general recommendation for the
treatment, of which seven explore preclinical psychiatric library shelf.
aspects. Reflecting current thinking, the em-          
phasis is on interactions between neuro-
transmitters, on autoreceptor functioning (par-
ticularly 5-HT B receptors) and the growing area
"
of neurotrophic factors. For example, there is a The Health Services Since the War. Volume II.
thoughtful attempt to provide a model that Government and Health Care : The British
integrates 5-HT, noradrenaline and dopamine National Health Service 1958–1979. (Pp. 988.)
function in the treatment of depression from The Stationery Office : London. 1996.
Tassin et al., who posit increased 5-HT function
#
as having a pivotal role in the action of Although it is some time since this magisterial
antidepressants (although it would have been study was first published, it is appropriate to
useful to discuss how antidepressants acting as review it in the 50th anniversary year of the
5-HT antagonists fit in). Most interesting in this National Health Service. In his first volume,
#
section are chapters that go beyond the mono- Charles Webster emphasized the ethical basis of
amine hypothesis. Rossby and Sulser explore the NHS, which aimed to universalize the best
post-synaptic events and gene expression through being free and comprehensive – words
although readers may be wary about the that sound like distant echoes in the post-
recycling of the circadian rhythm theory of Thatcher era. But in 1948, the collective pro-
depression. Grahame-Smith provides an vision of services and pooling of risks through
expansive discussion of mood disorders as a public finance were non-controversial ; implicit
reflection of abnormal neuronal adaptation in in this agreement, as Webster pointed out, was a
response to stress with synaptic homeostasis as a shared optimism about progress through the
Book reviews 1005

application of medicine. After 10 years of the to have worked with an enthusiastic and
NHS, though, it was clear that the task was a innovative Medical Officer of Health, but they
good deal more complex than had first appeared, were very thin on the ground.
not least through the consequences of these In 1962, Enoch Powell introduced the Hos-
technical advances in medicine. This review will pital Plan, which for all its faults – which were
be concerned primarily with Webster’s account many – was the first attempt to introduce any
of the mental health services, though clearly coherence into a chaotic system, controlled only
what happened to these was part of a more by the lack of capital. This plan embodied the
general picture. concept of the District General Hospital (DGH),
While this was an officially commissioned a landmark for psychiatry, which for the first
work, Webster makes no attempt to avoid the time became one of the core specialties. Like
political aspects of the story ; indeed, he makes it many aspects of the service as a whole, the DGH
very clear that very often, politics is the key to principle emerged rather suddenly and without
understanding what happened. From 1950, when much exploration, though it turned out to be
housing and local government were taken out of broadly right. There had, however, been some
the Ministry of Health, until 1968, when the precedent in the general hospital psychiatric
DHSS was established under Crossman, the units of the Manchester Region. Webster men-
Ministry was a political and administrative tioned these briefly in his first volume, but they
backwater. This meant that it counted little in probably deserved a large place in this story,
the Whitehall struggle for resources, particularly even if the London medical establishment
as Ministers came and went with bewildering remained mostly unaware of them.
rapidity. Those who have puzzled over the Although this volume starts generally in 1958,
failure to develop community care after the 1959 Webster uses it to discuss at length the Royal
Mental Health Act will find the answer in the Commission established in 1954 and the sub-
evidence Webster has unearthed of the sequent Mental Health Act. He shows that one
Treasury’s bitter opposition to any provision for of the obstacles to the development of com-
this purpose. This was part of the culture, prehensive mental health services was the dis-
initiated by the Treasury and eagerly taken up parity between hospitals, for which the Treasury
later by the political Right, that the NHS was paid 100 % of capital costs, and community
inefficient and wasteful – a view that ‘ assumed facilities, for which it paid only a proportion.
the status of an ineradicable myth ’. One might This dilemma was never resolved. Having failed
conclude that for many years, the community to obtain more than minimal resources for
care policy was little more than a sham. community care, ‘ the Ministry of Health fell
Webster’s verdict is that ‘ Although in the back on exhortation, giving publicity to hopeful
political rhetoric (it) was a high priority, in initiatives ’. In fact, it did very little for the next
practice it was treated as an expendable luxury ’. 10 years, and in spite of Enoch Powell’s threats
The expansion of community care also de- of destruction to the mental hospitals in his
pended on initiative and enthusiasm from local ‘ Watertower ’ speech of 1961, they actually had
health authorities, but these ‘ became one of the a new lease of life. Crossman recognized this
less attractive branches of local government reality, and advised Health Regions to con-
responsibility ’, while most Medical Officers of centrate on improving conditions in existing
Health ‘ pursued their responsibilities in the hospitals.
pedantic and restrictive spirit inherited from the The blueprint for a future pattern of mental
Depression period ’. This has usually been health services – Better Services for the Mentally
blamed on the local authorities’ loss of their Ill – did not appear until 1975, although prepar-
hospitals (including mental hospitals) in 1948, ations for it had begun several years earlier
but the rapid advances that were occurring at (Department of Health and Social Security,
this time in clinical medicine also made con- 1975). By then, economic conditions had de-
ventional public health increasingly unattractive. teriorated to such an extent that no firm promises
It received little stimulus or penalization from were made as to when any specific targets might
the Ministry of Health, which followed its be met. Webster is critical of the document,
traditional path of laissez-faire. I was fortunate seeing it as ‘ commendable for its pious ex-
1006 Book reviews

pressions, but deficient in practical content ’. Yet individuals, and therefore CFS will be perceived
it was a coherent, comprehensive, and in some differently by different clinicians and patients.
respects sophisticated programme ; few other The reader of the this book should find it easier
countries or other specialities have produced to understand the perspective of the authors in
anything comparable, as far as I know. One this well-organized edition than in other multi-
should not forget that it was drawn up nearly 25 authored review but, as noted by the authors,
years ago. Webster is also dismissive of the 1974 this book will not please everyone, particularly
NHS reorganization, which he believes ‘ reduced patients who refuse to accept that psychological
still further the place of the mental sector in the factors have an impact on CFS.
health service hierarchy ’. In my experience, that It is increasingly apparent that many illnesses
was not generally so, though the changes are either precipitated by or exacerbated by
involved a fundamental mistake in having one stress and while there are many patients with
tier of management too many. CFS who have no evidence of psychological
Next came the Royal Commission on the difficulties, CFS is considered a psychiatric
NHS, which made a strong plea for the retention disorder by some physicians and insurance
of most of the mental hospitals. This fell on deaf companies. This book clearly documents that
ears, particularly after the change of government CFS can occur after glandular fever (infectious
in 1979. Although it had always been axiomatic mononucleosis) and in settings where psycho-
that none of these hospitals would be closed logical aspects make a small or negligible
until a complete alternative service was in place, contribution to the problem, but it is also
this principle began to be steadily eroded in the important to note that CFS is one of those
period after this Volume concludes. Unfor- disorders where the interaction of the brain and
tunately, it involved running two services at the the endocrine and neurological systems play an
same time while the change-over occurred, and important role in the pathogenesis.
the financial implications of this were never This book has an extensive and up-to-date
solved. Nevertheless, psychiatry in 1979 had bibliography that will be useful to any reader
changed out of all recognition since 1958. From wishing to undertake an evaluation of CFS or
now on, though, it was to be downhill all the any of its components. Because of the complexity
way. of this disorder, however, it is impossible for any
  book to cover all of the relevant issues completely
and to everyone’s satisfaction. This reviewer has
some concerns that do not detract from an
REFERENCE overall appreciation of the book’s value. First,
Department of Health and Social Security (1975). Better Services for the importance of infection in the pathogenesis
the Mentally Ill. Cmnd. 6233. HMSO : London. of CFS may play a greater role than accepted by
the authors. While they acknowledge that CFS
Chronic Fatigue and its Syndromes. By S. can follow infectious mononucleosis, as orig-
Wessely, M. Hotoph and M. Sharpe. (Pp. 416) inally suggested by Jones and Straus (1987), they
Oxford University Press : Oxford. 1998. do not evaluate sufficiently the clusters of
‘ epidemic neuromyasthenia ’, which contain sig-
This book is a comprehensive and well written nificant numbers of CFS cases. Other minor
review of the history and current status of concerns include statements that are of con-
chronic fatigue syndrome (CFS). It differs from siderable potential importance but not well
other authoritative books on the subject of CFS documented, such as the data for the allegation
which are multi-authored and provide a number that NSAIDS are responsible for immune
of differing opinions, some of which are com- dysfunction.
pletely in disagreement, by providing a synthesis  
of the literature from a more uniform per-
spective. But CFS is a complicated problem,
being the final common pathway for a het- REFERENCE
erogeneous disorder, which can have multiple Jones, J. F. & Straus, S. E. (1987). Chronic Epstein-Barr virus
triggers and different manifestations in different infection. Annual Reviews in Medicine 38, 195–209.
Book reviews 1007

Child Homicide. By A. Wilczynski. (Pp. 278 ; questions the validity of its use as we move
£45.00.) Greenwich Medical Media : London. towards a new century. Similarly, the author
1998. stresses the differential response of the courts
and public to the killing of children outside the
A scientific review of an act that is in itself rare family unit, which presents as in recent cases in
but attracts such a high level of public interest the UK, as the greatest threat to our social
and associated rhetoric rather than facts, is to be fabric.
welcomed. Throughout the text the author The author gives a clear and useful review of
stresses the limitations of both previous and her Child Death Reviews Teams and their role in
own research, at times dwelling on this to the pinpointing flaws in the system and, importantly,
extent that the reader is discouraged from as providing prevention services. In keeping
reaching the essential parts of each chapter, with the recent Consultation Paper England and
which do increase factual knowledge, under- Wales 1998, Working Together to Safeguard the
standing of and effective multisystem approaches Child the author emphasizes the role all agencies
to prevention of child homicide. have in Child Protection, including the medical,
The focus of the book is on experience and psychiatric services, drug and alcohol agencies,
data in England drawn from 65 case files from in order to avoid the ultimate failure of any
the Director of Public Prosecutions and two social system – a child homicide.
Australian studies, the first The Child Protection Anna Wilczyviski has achieved with this text
Council Study, the second the Judicial Com- a comprehensive review of a difficult subject
mission Study. Evidence is adduced from the matter and has drawn from it with a useful
American literature but there is little reference reference section and bibliography, broader
made to the history of child killing through the implications for all of us whose day-to-day work
ages and the impact of different cultures and touches the field of child protection, risk
belief systems. assessment and effective risk management.
In describing the phenomena of filicide, the          
author highlights the likely under-estimation of
child homicide assessing that the true incidence
of child homicide is some three to seven times
higher than recorded by official statistics. Classi- The Management of Depression. Edited by S.
fication based on motivation covers the pre- Checkley (Pp. 476 ; £60.00.) Blackwell Science :
viously well trodden ground of retaliation, Oxford. 1998.
discipline, unwanted child, secondary altruism
psychosis and jealousy but also increasing Depression, like most common mental disorders,
understanding through an analysis of the dy- is widely written about by psychiatrists. Unfortu-
namics of power, gender and social roles within nately, on many occasions the psychiatrists who
the family exploring the different meaning for write have little idea about what most patients
male and female perpetrators. Although not with the condition they are writing about are
advocating the replacement of individualized actually like. They generalize from their own
assessment of a family and its needs the author experience of highly atypical cases, and in
draws upon the increasing use of risk assessment consequence give inappropriate advice to those
and the practical use of risk factors, in both the who actually see the majority of more ‘ typical ’
field of child protection and the wider field of cases. The primary–secondary care interface has
forensic assessments. often seemed a battleground over the past 30
Emphasis of the Criminal Justice response on years, with psychiatrists asserting that general
the use of a psychiatric plea and the ‘ good practitioners ‘ miss ’ a large proportion of de-
mother ’, the differential response to males and pressed ‘ cases ’, and under-treat those they do
females is extended to look at differential recognize, in the absence of any convincing
responses to women who do and do not conform evidence base for clinical guidance.
to gender stereotypes. The author calls for the It therefore comes as something of a relief to
medical principles on which the Infanticide Act find a work, written and edited almost entirely
1938 are based to be further reviewed and by psychiatrists and mental health professionals,
1008 Book reviews

which largely avoids this pitfall. Like a well- What are the highlights ? The most striking
known DIY product, this large and handsomely remark in the book is that of David Goldberg,
produced volume does what it says on the cover. discussing drug treatment in the primary care
The editor and his contributors have made an context (p. 35), where he states that : ‘ (the use
ambitious attempt to synthesize the current of) a placebo is a matter of personal preference ;
knowledge-base for the topic, and they have what is important is that potentially dangerous
clearly worked to a tight timescale to produce a drugs are not used for what is, in fact, a placebo
book that is both up-to-date and comprehensive. response ’. Tirril Harris gives a welcome review
The book opens with discussion of the of the current state of life events research, and
epidemiology of depressive illness, and current Hotopf and Wessely, in one of the more
aetiological theories are reviewed, before the systematic chapters, review depression in the
extensive coverage of treatment approaches physically ill.
begins. Optimal methods of delivering treat- This is a long and expensive book that
ments are discussed, and the work closes with succeeds in its aim of collecting the available
discussion of special groups such as the elderly knowledge about its topic in early 1998, and it
and the physically ill. There is slight overlap thus deserves to be widely read by psychiatrists,
between the chapter contents, but in the main ideally as soon as possible. My only reservations
this is avoided, largely one suspects because the are that it contains rather less to inform the
majority of the contributors work (or have ‘ front-line troops ’ who see most of the patients
worked) in the same institution. Cronyism is with this illness, and that its sell-by date is not
now widely condemned, but there are still clearly marked on the jacket.
occasions when it may have value !            

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