People have used psychoactive substances to dull and deaden pain, misery and suffering since time immemorial, but only recently, in the last few decades, have people been persuaded that what they are doing in this situation is rightly thought of as taking a remedy for an underlying disease. The spread of the use of prescription drugs has gone hand in hand with the increasing medicalization of everyday life, and a corresponding loss of the previous relationship that people had with psychoactive substances.
Elizabeth Gaskell’s novel Mary Barton was originally to be named after Mary’s father John Barton, a working class factory hand addicted to opium (1). The novel depicts the unimaginable poverty and exploitation of industrial Manchester that made opium-induced oblivion an appealing escape. Although Gaskell clearly disapproved of John ‘s addiction, the reader is left in no doubt that opium use in 19th century Britain was a symptom of a deep social malaise. John is a victim of his social environment, coupled with the overwhelming grief of losing his beloved wife, both of which are understood to have contributed to John’s gradual decline into drug-induced torpor and belligerence.
Nowadays, John Barton would undoubtedly be diagnosed with depression, and he would be offered Prozac and Zopiclone in place of opium. He would be told that although ‘social factors’ might have precipitated his feelings, he suffered from an underlying chemical imbalance, which drugs could help to remedy. Instead of taking a substance whose properties he was familiar with, however destructive they turned out to be, he would be taking something whose effects on the human psyche have never been properly investigated, and are barely even described. He would be discouraged from evaluating how the drugs affected him, from working out whether they helped or hindered his daily activities, or whether their effects were pleasant or disagreeable. Moreover, by suggesting that the problem lay in his brain, he would be led to believe that the circumstances he lived and worked in, the loss of his wife and the loss of his job were merely incidental details, and that challenging his situation would be quite pointless and irrelevant to his state of mind. When the first lot of pills inevitably failed to eradicate his despair, he would be offered other miracle cures to enhance or replace the first ones.
Readers of the modern version of Mary Barton would not be roused to righteous ire and indignation about the state of the urban poor, as the readers of writers like Gaskell and Dickens were intended to be. They would only pity the unfortunate character whose defective make-up led to his downfall.
We have been fed a myth about the nature of psychiatric drugs for decades now, the myth that they can rectify mental disorders by targeting an underlying mechanism. We have been told that they are specific treatments, in the same vein as insulin for diabetes, which act by reversing the abnormalities that give rise to the symptoms of a particular disorder. As this idea has taken root we have come to understand more and more of our daily troubles in terms of our brain chemicals (2), in the process further contributing to the demise of the previous lay understanding of the nature of psychoactive substances and how they modulate psychological states.
Drugs have now been starkly divided into the good and the bad: the prescribed medication which people must take however awful it makes them feel, and the ‘recreational’ substances that are increasingly and often hysterically vilified (3). At the same time that people are told they should not stop taking their antidepressant, they are constantly reminded of the dangers of alcohol and cannabis. People are encouraged to seek licit and prescribed emotional suppressants, but disparaged (and prosecuted if it’s the wrong substance) for seeking pleasure through chemical means. The modern citizen is caught in a constant flux of contradictory messages.
David Healy has described the transformation of ‘everyday nerves’ over the early 1990s through the marketing of the new Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants like Prozac and Seroxat (4). Problems that had previously been conceived of as anxiety, to conform to the stereotypes portrayed in the marketing of benzodiazepines, started to be understood as a mood disorder, and the notion of ‘depression’ expanded to encompass almost all forms of dissatisfaction and discontent. The drug companies were careful to market their new range of drugs for depression as medicines, which worked by reversing the individual’s defective biochemistry. The tardy acknowledgment that the benzodiazepines were dependence-inducing, coupled with criticism of their widespread use as a chemical pacifier for the over-burdened or frustrated usually female recipient, had threatened to bring the whole enterprise of the mass treatment of common-or-garden misery into disrepute. The SSRIs had to be presented as something different, as a new and miraculous cure for a bona fide disease, a disease which by mysterious coincidence had only been fully recognised when the SSRIs arrived on the scene. So the drug companies went about marketing the serotonin theory of depression, sweeping much of the psy professions along with them, with only a few lonesome voices belatedly pointing out that the emperor had no clothes (5).
The success of Prozac inspired a frenzy of activity, with companies vying to take a piece of the massive antidepressant market. When the capacity for persuading people they were depressed was saturated, new disorders were promoted to draw in further swathes of the population and extend the patents on the new antidepressants. Disorders like social anxiety disorder and premenstrual dysphoric disorder were promoted by glitzy campaigns orchestrated by public relations companies masquerading as grass-roots organisations (6).
In the late 1990s the makers of atypical antipsychotics started to eye this market too, and set about constructing an essentially new problem, which they concealed under the old concept of ‘manic depression’. The new thinking suggested that ‘depression was only half the story’ (7) (P 190), and that emotional ups and downs were a pathological condition which went under the rubric of ‘bipolar disorder’. People were encouraged to monitor their moods with ‘mood diaries’ to detect the condition, and hoards of people started to identify their experiences in this way, egged on by the endorsement of celebrities like Stephen Fry.
Eli Lilly obtained a licence for the use of Zyprexa in bipolar I disorder (the new name for the old concept of manic depression) in 2000, but the target population was never the small number of people with this rare and serious condition. The target, as revealed in advertisements as well as the leaked internal documents known as the ‘Zyprexa papers,’ was the huge population of people who currently identified themselves as depressed, worried, unhappy, unstable, or almost anyone who could be persuaded there was something wrong with their life (8).
‘Zyprexa balances the chemicals naturally found in the brain’, we are told of Lilly’s new blockbuster (9), a statement that provides no hint of the serious metabolic consequences, massive weight gain and brain volume reduction the drug can produce (10), or the large settlements Lilly has made with litigants in the United States and Canada (11). Lilly is not alone. The makers of Seroquel, another ‘atypical’ antipsychotic have also positioned their product in the depression and bipolar market, successfully ensuring that it too becomes one of the top-selling drugs of all time (12). The combination of obtaining licences for vague and easily expandable conditions, with illegal marketing for unlicensed indications (13) has ensured that the antipsychotics, once reserved for the treatment of the most severely disturbed, have broken out of the now metaphorical asylum and into the community. They are the newest ‘opium of the people.’
People living in western societies may no longer suffer from the desperate material deprivations of the likes of John Barton, but the demands and pressures of modern life, the competitiveness, the performance management, the increasing insecurity, the inequality, the constant broadcasting of wealth, extravagance and power into the homes of ordinary people, contribute to a society where everyone feels inadequate and dissatisfied, and no one is secure: fertile ground for the pharmaceutical industry and the psy professions. From this point of view, John Barton’s tragedy was that in revenging himself on the mill owner’s son, he left the system not only intact, but strengthened. At least he did not think the enemy was his brain!
This essay was first written as a tribute to Professor Mark Rapley, RIP, for a special memorial edition of Clinical Psychology Forum.
(1) Gaskell E. Mary Barton. London: Penguin Books; 1848.
(2) Rose N. Becoming neurochemical selves. In: Stehr N, editor. Biotechnology, Commerce and Civil Society.New Brunswick, New Jersey: Transaction Publishers; 2004. p. 89-128.
(3) DeGrandpre R. The Cult of Pharmcology. How America became the world’s most troubled drug culture. Durham, NC: Duke University Press; 2006.
(4) Healy D. Shaping the intimate: influences on the experience of everyday nerves. Soc Stud Sci 2004 Apr;34(2):219-45.
(5) Lacasse JR, Leo J. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med 2005 Dec;2(12):e392.
(6) Koerner BI. Disorders made to order. Mother Jones 27[July/August]. 2002.
(7) Healy D. Mania: a short history of bipolar disorder. Baltimore, MD: John Hopkins University Press; 2008.
(8) Spielmans GI. The promotion of olanzapine in primary care: an examination of internal industry documents. Soc Sci Med 2009 Jul;69(1):14-20.
(9) Eli Lilly. How Zyprexa works. www zyprexa com/schizophrenia/pages/howzyprexaworks aspx 2011 [cited 2011 Mar 25];Available from: URL: http://www.zyprexa.com/schizophrenia/pages/howzyprexaworks.aspx
(10) Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology 2005 Sep;30(9):1649-61.
(11) Boyle T. Class action settlement in drug for schizophrenia. healthzone ca 2010 June 30 [cited 12 A.D. Nov 30];Available from: URL: http://www.healthzone.ca/health/newsfeatures/article/830750–class-action-settlement-in-drug-for-schizophrenia
(12) Thase ME, Macfadden W, Weisler RH, Chang W, Paulsson B, Khan A, et al. Efficacy of quetiapine monotherapy in bipolar I and II depression: a double-blind, placebo-controlled study (the BOLDER II study). J Clin Psychopharmacol 2006 Dec;26(6):600-9.
(13) United States Department of Justice. Pharmaceutical company Eli Lilly to pay record $1.415 billion for off label drug marketing. www justice gov/usao/pae/News/Pr/2009/jan/lillyreleaase pdf 2009 January 15:1-4.