by Elliot Valenstein
Free Press, 1998
Review by Jonathan M. Metzl, M.D. on Dec 31st 1998
There is a moment of truth that takes place, very often, near the end of the clinical interaction between a psychiatrist and a patient. The psychiatrist, having heard the patients description of symptoms, recommends treatment with a "psychotherapeutic" medication such as an antidepressant or an anxitolytic. The recommendation is made with confidence in prescription forged through the experience of seeing many patients return to their lives. The patient, meanwhile, having come to the psychiatrist with symptoms of pain, dejection, or anxiety, is happy to learn that there is a "psychotherapeutic" medication that might well make life a bit better. But as the psychiatrist reaches for the prescription pad and begins to write.. "Prozac, 20mg, #30, 2 tablets each morn....," the patients asks a fateful question: "By the way, doc, how do these medications work anyway?"
The question, amazingly enough, often results in a disquieting pause. Sometimes, the physician will take the scientific approach. "What we know about their in vivo action is simply theory. There are many, many neurotransmitters in the brain. We know medications such as Prozac work on the Serotonin system, thought to be involved in the mechanism of depression..." Sometimes, the response can sound a bit defensive. "Well, , let's just say they work." And sometimes, one can just change the subject. "Well, how about this weather, huh?" But beneath these responses, or lack thereof, lies a discomforting truth: We are not entirely sure of the mechanism of action, broadly speaking, of many psychotropic medications. Moreover, while we have ample evidence attesting to these medication's effect on brain chemistry, much remains to be said about the connection of brain chemistry and emotional well being.
The dilemma of this moment, described in intricate detail, is the subject of Elliot Valenstein's compelling new book, Blaming the Brain: The Truth About Drugs and Mental Health. The book is the latest in a line of recent works examining the effects of psychiatry's turn, from psychoanalysis to biology, in the last 50 years. Blaming the Brain, however, is not a history of systems. It is thus neither wholly a history of power dynamics (Shorter, A History of Psychiatry); nor entirely a narrative of discovery (Healy, The Antidepressant Era); nor an expose of a modern day conspiracy theory (Breggin, Toxic Psychiatry). The book is, in part and at times to a fault, each of these at once. But Valenstein's interjection into this debate, and his contribution to it, lies not above, but within these structures of care: Valenstein re-reads the psychiatric literature of the last 50 years, seeking a rationale for the widespread (and often unquestioned) use of medications in clinical practice, and for the almost unquestioned popularity these medications have achieved as a result. In so doing, the author examines the seemingly basic assumptions of psychiatry in the age of Prozac: that abhorrations of personality are neurochemically based; and that psychotherapeutic medications, in a re-balancing act, effectively correct these abhorrations.
Valenstein approaches these basic tenets with a scientist's skeptical eye, much as he did with psychosurgery in his most widely acclaimed work, Great and Desperate Cures. Here, too, the results are not pretty. The author systematically calls into question the "science" which seeks to rationalize the widespread use of psychotherapeutic medications. His argument is not that the science behind biological psychiatry is wrong, or even that it is misguided; but rather, that it has not adapted to the times, nor challenged itself to do so. ("The psychiatric literature rarely addresses how or why an excess or deficiency in serotonin or dopamine activity explains any particular mental disorder" (96).) The same can not be said, however, for the endlessly expanding pharmaceutical industry. Thus, while new drugs seem to flood the market each day, entering into a medical system based upon their quick and effective distribution, the rationale for their use has not changed at all. "Considering what we have learned about neuropharmacology," Valenstein writes, "it is indeed amazing how little biochemical theories of mental disorders have changed over the last half-century" (95). A story that began starring serotonin, norepinephrine, and dopamine, in other words, has kept the same, aging actors over 50 years. This despite Valenstein's contention that "It was discovered that the brain has many more receptors than anyone suspected when the (biochemical) theories were first proposed. Drugs that were thought to act on only a few neurotransmitter systems are now known to initiate many different changes in the brain, and this has enormously complicated the problem of determining what is responsible for any therapeutic gain that is achieved" (94).
The results of this situation forms the basis for some of Valenstein's most though-provoking criticisms of contemporary psychiatry: That it has failed to purse the broader implications of how its treatments "work," and has instead become complacent with oversimplified and frequently reductive explanations. Moreover, that in the process, it has lost sight of-or willfully excluded- many other untold parts of the story of mental illness. These range from chemical explanations, to a more in depth approach-to the psychology of psychopharmacology.
Psychiatry and neuroscience are not, however, the only bad guys in this story. Their reductive tendencies, even in the face of compelling evidence, receives a great deal of assistance from pharmaceutical companies. In the book's highly interesting, although somewhat under-theorized sixth chapter, Valenstein addresses the pharmaceutical industry's role in both perpetuating, and restricting, the development of new compounds. Valenstein further examines the troubled notion of pharmaceutical advertising which, by many arguments, both informs physicians (and now the public) of new products, and at the same time tries to sell them. In a rather Foucaultian questioning the definition of information, Valenstein argues that "These two missions-promotion and education-are likely to conflict, and when they do it will not often be the promotional role that gives way"(175).
The book does have a few serious flaws. Organizationally, it is at times quite difficult to follow. This is especially the case in the book's early chapters, which tell of the now-familiar (Healy, Shorter) and unnecessary detailed history of early psychopharmacology. The result is a sense of too many narratives being told at once-this despite (and perhaps the cause of) the numerous bold subheadings throughout the work. These narratives only serve to dilute the strong arguments that, in subsequent chapters, follow. Worse, the book falls prey to its own criticisms: Valenstein attacks psychiatry for not concentrating on the "psychological" aspects of mental illness, but then writes an entire book in which these aspects, in theory and in praxis, are never mentioned at all. The book for example (and much like Healy's recent work), does not at all mention the psychoanalytic community's reaction to the developments described.
And yet this is a very good, and very important book for one simple reason: what it does, it does very well. It effectively describes the arguments assumed by the "biological" revolution in psychiatry. It convincingly assesses the evidence in support of these assumptions. And it compellingly discusses the gaps between assumption and "fact." The result is a work that both even-handedly presents the psychotherapeutic advances of the past fifty years; and at the same time, provides a very important, and very timely, act of deconstruction. The result, one would hope, would be a more rounded understanding of the impact, and the limitations, of psychotropic drugs. And a more thoughtful discussion, in many varied treatment rooms, of biological psychiatry's broadly conceived "mechanism of action."