also, i found this interesting WRT to what Healey says here:
"As with Zelmid before it, there was a natural interest on the part of clinicians to try fluvoxamine. In the 1980s, this meant that the first patients to get a new antidepressant would be patients who were hospitalized with depression, who seemed unresponsive to other therapies. This is not a promising patient group on whom to try out a new drug. It has since become clear that SSRIs do not do very well for in-patient depressions. This lack of response along with a severe nausea in a significant number of patients led to the clinical impression that fluvoxamine was unlikely to make significant inroads into the antidepressant market. It never did." http://www.healyprozac.com/Book/Introduction.doc
In general, SSRIs don't work very well for people hospitalized with major depression.
BTW, Healey has this fascinating lecture online which was part of a lawsuit he launched against UofT for violating academic freedom. I thought Chuck Grimes would like it. It's about the history of public policies toward drugs, : the embrace of drugs that control populations and the rejection and demonization of drugs that destabilize society.
http://www.pharmapolitics.com/feb2healy.html
Deinstitutionalization of Patients:
"Why is there such an extraordinary development? Only 16 years after the discovery of chlorpromazine, which liberated the insane from their straitjackets. The great boast of the advocates of chlorpromazine was that it had restored humanity to the asylums. Previously, lunatics had been guarded by jailers, who treated them brutally. Now it was possible for therapists to see the humanity of their patients and talk to them. The level of noise in the asylum has fallen.
However, the times have seen the emergence of antipsychiatry and the antipsychiatrists respond that real straitjackets have simply been replaced for chemical straitjackets, for the camisole chimique. That indeed there is silence within the walls of the asylums, but this is the silence of the cemetery.
What is happening? There is a revolution in progress. A revolution that stems in great part from the new drugs and the interaction between these drugs in the social order in which people live. The drugs have played or threaten to play a huge part in a changing of the social order. The discovery of chlorpromazine by Delay and Deniker was the discovery of a drug that acted on a disease in order to restore a person to their place in the social order. In contrast, Henri Laborit's discovery of chlorpromazine the previous year, which led to artificial hibernation was the discovery of a drug which produced an indifference, so that taking this kind of drug taxi drivers drove through red lights.
And out of the same test tubes and laboratories from which chlorpromazine came, came LSD and the psychedelics, Valium and the benzodiazepines and other drugs. These were not drugs that restore people to their place in the social order. These were drugs that had the potential to transform social order.""
and On the Deinstitutionalization of Psychiatry:
" By 1966, a large number of studies had confirmed his observations that there was a marked and severe physical dependence on antipsychotics that was present in large numbers of people taking them, even at low doses for a relatively short period of time. A dose of 1 mg Stelazine given for several months might produce a state where the individual could never stop therapy ever again. This led to the concept of therapeutic drug dependence. A concept that blows a hole in most theories of addiction we have. These drugs produce no tolerance, no euphoria. They produce enduring post-discontinuation changes that are as extensive and long lasting as the changes underpinning current disease models of addiction. But recognition of antipsychotic dependence vanished around 1968, when the War on Drugs was declared.
Psychopharmacology was faced with a political problem. The problem was how to distinguish drugs, which restored social order from drugs, which subverted the social order. The 'decision' was made to categorise as problematic and dependence producing any drugs, which subverted the social order. This political rather than scientific decision set up a crisis a few years later when physical dependence on the benzodiazepines emerged. This broadened to an extraordinary crisis, which led to the obliteration of the anxiolytics and indeed almost the whole concept of anxiolysis. By 1990, physicians in Britain and elsewhere regarded benzodiazepines as more addictive than heroin or cocaine - without any scientific evidence to underpin this perception (Slide 9).
You may smile indulgently at this idea now, but the consequences could not have been more profound. To appreciate these, you simply need to look to Japan, where there never was a crisis with the benzodiazepines. In Japan, the concept of an anxiolytic remains respectable and the market for anxiolytics is much greater than the market for antidepressants. No SSRIs, not even "Prozac" are available on the Japanese market for depression. The era of Depression that we have lived through in the 1990s in the West has arguably been a politically and economically constructed era that bears little relationship to any clinical facts. An era that has changed popular culture by replacing a psychobabble of Freudian terms with a new biobabble about low serotonin levels and the like.
As the 1990s ended, dependence on the SSRIs appeared. Is another group of useful drugs going to be lost to us the way the benzodiazepine were lost? Do we understand enough about what happened to the benzodiazepines to be able to guarantee that the SSRIs will not suffer the same thing? Do we understand how the concept of dependence on antipsychotics could have vanished just in time when a very obvious dependence syndrome -- Tardive dyskinesia -- was causing so much grief to the psychiatric and pharmaceutical establishments? If we don't understand what happened here, we can offer no guarantees for the future.
Coming from my perspective the antipsychiatrist arguments that madness doesn't really exist are simply wrong. But the unarticulated force behind the antipsychiatrists' arguments was that they perceived that in some way the ways in which we govern ourselves had changed and that psychiatry was now part of the new order of government. Everyone agreed there had been a de-institutionalisation. But was it a de-institutionalisation of patients? Where patients are concerned, in Britain at least they are being detained at 3 times greater rate than 50 years ago. They were being admitted at a 15 times greater rate than before, and on average, patients are spending a longer time in service beds than ever before in history. New conditions such as personality disorders were being admitted to hospital and the management of violence and social problems was becoming an issue for psychiatry (Slide 10). The figures are more consistent with a de-institutionalisation of psychiatry. Unselfconsciously, psychiatrists claim we are treating more patients than ever before. We are. "
May 1968: Who Won?
" This was to lead to the greatest possible symbol for the times. On the next slide, you can see the protests in Paris in 1968. The students are on the march. Their march takes them to the office of Jean Delay, which they ransacked. Delay is forced to retire. He has no sympathy for the new world, in which students can expect to address the professors in informal terms (Slide 11).
But the fact that we are all here today suggests that we won, doesn't it? You may not know how we won. No history has ever been written of the period. No textbooks of psychiatry record the sacking of Delay's office. None refer to the fact that the key figures behind the revolutions of late 1960s, were psychiatrists or philosophers appealing to examples from psychiatry -- Franz Fanon, Michel Foucault, R.D. Laing, Thomas Szasz, Erving Goffmann, Herbert Marcuse. In the face of a repression like this, you may feel that the ghost of Freud is hovering somewhere, laughing at us, and perhaps you are right.
The truth is, we didn't win. The world changed. Both psychiatry and anti-psychiatry were swept away and replaced by a new corporate psychiatry. Galbraith has argued we no longer have free markets; corporations work out what they have to sell and then prepare the market so that we will want those products (Slide 12). It works for cars, oil, and everything else, why would it not work for psychiatry? Prescription only status makes the psychiatric market easier than almost any other market - a comparatively few hearts and minds need to be won."
Risk Management
" This was not just the replacement of theology and philosophy - the qualitative sciences - by a new set of quantitative sciences. The new statistics set up something else. They set up a market in futures. A market in risks. We were on our way to becoming a Risk Society (Slide 16). In the case of IQ test, deviations from the norm were now something that predicted problems in the future. Parents sought out psychologists in order to improve the futures for their children. This was how we would govern ourselves in the future. Through the marketplace.
Psychotropic drugs entered this new market in many different ways. The oral contraceptives for instance are clearly not for the treatment of disease. They were a means of managing risks. Where once, the risks of eternal damnation had been those that concerned people the most, now it was a much more immediate set of risks - indicating that we had switched one set of future risks as the key ones that determined our behaviour for another set more immediate set (Slide 17). The best selling drugs in modern medicine do something similar - they don't treat disease. They manage risks. This is clearly true of the antihypertensives, the lipid lowering agents and other drug (Slide 18). It is true also of antidepressants, which have been sold on the back of efforts to reduce risks of suicide (Slide 19).
We are in an era, which is popularly portrayed as an "Evidence Based Medicine" era. What can go wrong if we have clinical trial evidence to demonstrate what works and what doesn't work, if we but adhere to this evidence (Slide 20). What more can we do than that?
Arguably, the term "Evidence Biased Medicine" would be more appropriate. Clinical trials in psychiatry have never showed that anything worked. Penicillin eradicated a major psychiatric disease without any clinical trial to show that it worked. Chlorpromazine and the antidepressants were all discovered without clinical trials. You don't need a trial to show something works. Haloperidol and other agents worked for delirium and no one ever thought to do a clinical trial to support this. Anaesthetics work without trials to show the point. Analgesics work and clinical trials aren't needed to show this. Clinical trials nearly got in the way of us getting fluoxetine and sertraline.
What clinical trials demonstrate are treatment effects. In some cases, these effects are minimal. One may have to strain with the eye of faith to detect the treatment effect. The majority of trials for sertraline and for fluoxetine failed to detect any treatment effect. This is not evidence that sertraline or fluoxetine do not work. In clinical practice many of us are under no doubt that these drugs do work. It is, rather, evidence of the inadequacy of our assessment methods. To show that something works, we would need to go beyond treatment effects to show that these effects produce a resolution of the disorder in a sufficient number of people to outweigh the problems such as dependence syndromes that these drugs also cause. If our drugs really worked, we shouldn't have 3 times the number of patients detained now compared with before, 15 times the number of admissions and lengthier service bed stays for mood and other disorders that we have now. This isn't what happened in the case of a treatment that works, such as penicillin for GPI.
Aside from the inadequacy of our clinical trial methods, professors of psychiatry are now in jail for inventing patients. A significant proportion of the scientific literature is now ghost written. A large number of clinical trials done are not reported if the results don't suit the companies' sponsoring study. Over trials are multiply reported so that anyone trying to meta-analyse the findings can have a real problem trying to work out how many trials there have been. Within the studies that are reported, data such as quality of life scale results on antidepressants have been almost uniformly suppressed. To call this science is misleading.
One of the other aspects of the new medical arena is that the most vigorous and hostile patient groups of the antipsychiatry period have been penetrated by the pharmaceutical industry. Other patient groups have been set up de novo by companies. Part of the market development plans for many drugs these days include the creation of patient groups to lobby on behalf of a new treatment. Meetings are convened for pharmaceutical companies specifically to advise and train on how to set up such groups."