Issue 8 Pharmacopia Fall 2002
Me, Myself, and Super-Me: An Interview with David Healy
David Serlin and David Healy
Since the 1980s when drugs like Prozac first appeared, clinical psychologists, talk show mavens, and writers in every corner of the globe have weighed in on their cultural significance. But long before Prozac reared its becalmed head, the development of anti-psychotic drugs like chlorpromazine in the 1950s, and anti-anxiety medications like Valium in the 1960s, ushered in a new era in drug research and drug marketing that changed our social contract with the health care industry.
One of the things that distinguishes the modern pharmaceutical era is a thing called “rational drug development.” Since the 1940s, companies have been increasingly able to manipulate different molecules to produce the outcomes that they want. From that point of view, drug development has become more rational.
What people fail to appreciate is that we didn’t have a pharmaceutical industry before the mid-1940s. We had a few companies, like Hoffman-LaRoche, which go back about a hundred years or so. But most of what are thought of as pharmaceutical companies now were either divisions of larger chemical companies, or they were chemical companies specializing in what were called patent medicines. Around the 1930s or 1940s, chemical companies began to realize that the pharmaceutical divisions were probably big enough to stand on their own two feet. Some of them began to think, well, we should try to get into the business of research-based pharmaceuticals. At the same time, there was an increasing capacity to produce the kinds of compounds that they wanted. The trick then was to figure out what compounds chemical companies should be trying to produce.
One of the problems we have at the moment, in terms of mental illness, is that pharmaceutical companies are not getting much steer either from the neuroscientists or clinical psychiatrists as to just what kinds of compounds are needed, what kinds of targets we would like “magic bullets” to hit. In lieu of that, they’re producing an increasing string of what gets called “me too”-type compounds. They each produce the same kind of compound rather than producing something more breakthrough.Do you think that the focus on the brain is a distinct moment in pharmaceutical history as opposed the industry’s focus on drugs that target different parts of the body?
No, I don’t particularly think the development of drugs that work on the mind appeared different, at least initially to the pharmaceutical companies. During World War II, governments in Europe and the United States were beginning to realize that putting funding into medical research could pay off. The fact that you could go and systematically produce compounds had clear implications for the postwar world. The idea that states could put funding into basic research, which pharmaceutical companies would then capitalize on, was a model that was born not out of drugs to do with the mind but rather out of treatments like penicillin, treatments for malaria, and endocrine treatments. After World War II, you get great public enthusiasm for new drugs like penicillin and cortisone, so that putting taxpayers’ money into research seemed to the general public something worth doing. The public was prepared to endorse this kind of development.In the 20th century, pharmaceutical companies have focused on trying to bring the “deviant” or “aberrant” body type into line with what is supposedly normal. Was brain research highlighted in a particular way during the postwar era so as to make the arrival of a new class of psychopharmacological drugs parallel with other kinds of normalizing technologies?
One of the things that happened, of course, is that in trying to “normalize” people, we also made them deviant. The production of LSD in the late 1950s comes on stream at approximately the same time as chlorpromazine. We tried to make sure that the new drugs we produced would not be LSD-like or opiate-like. But LSD and the opiates appeared to many to underpin the transformation of social relations that happened during the 1960s. They arguably played a role in the rise of oral contraceptives and drugs like this. They dissolved the social hierarchies of both the pre-war and post-war periods, and became a threat for this reason.
Up until the 1960s, the dominant medical model had been to treat people in order to put them “right.” Putting them right meant putting them back into their place in the social order. What you get with both the oral contraceptive and drugs like Valium, Librium, and LSD is a group of drugs which seem not to be restoring people to their place in the social order but arguably a set of treatments that will subvert that order. These drugs are going to leave women as liberated as men; they’re going to make the shy and timid people who take Valium and Librium able to handle strain and stress in a way that they haven’t done before. These are disinhibiting drugs. Then you’ve got drugs like LSD, which suggested to people that the entire social order was an artifactual one held in place by forces of power. Once the scales drop from your eyes, you will begin to realize we’re all equals.
In a curious kind of way, what you’ve got from early on are physical treatments that “normalize” people that have a strong parallel with treatments like cosmetic surgery. Endocrine treatments like growth hormones moved fairly smoothly from being treatments for a disease to being treatments that “normalized” people and helped people grow up to the height that we would wish them to be. But treatments in the psychiatric domain have run a much rougher course. People have had to grapple with notions of whether we really want to equalize the playing field, whether we do want to give people the means to enhance their personalities so that they will be equal to everyone else.What was the response of pharmaceutical companies in the 1960s to people like Timothy Leary and others who were on the border between the sanctioned world of pharmaceutical use and the underground world of the counterculture?
When amphetamines first appeared back in the 1920s and 1930s, some work that was done with animals indicated that “normal” animals could perform better than normally. The response from pharmaceutical companies and mainstream orthodox neuroscientists at the time was, “This can’t be true. Drugs will treat illnesses, but they won’t enhance any kind of performance.” What you get in the 1960s is the prospect that performance can be changed. We can potentially exceed what before had been thought to be the normal limits of human striving.
The pharmaceutical industry, faced with this, tended to act very conservatively. When, in the 1970s, scientists discovered that some antidepressants that act on the serotonin system could treat ejaculatory problems in men and enhance their sex lives, pharmaceutical companies, far from being interested in this kind of idea, actually buried the actual data. They refused to support publications of any sort on this kind of issue.Was this a public relations problem for them?
No. The industry is just intensely conservative. When drugs like RU-486 [the “morning after” pill] first surfaced, Roussel Uclaf thought that they would shelve it because they thought however it might be used in certain parts of the world, other parts would be unhappy with a drug like this. Not only would people not use this drug but they wouldn’t use any Roussel drugs at all. This is the kind of calculation that companies have in mind. They’ll say, “Well, we have these drugs which work on the serotonin system which can influence sexual functioning. But if we make a big deal of this, people won’t use these drugs and they won’t use any of the rest of our drugs, either.”
So in one sense it’s public relations, but it goes further than that. In the 1950s and 1960s, when it became clear that many of the new drugs that work on the brain could alter sexual behavior for lab rats or rabbits, companies shut down programs of research in this area. They actually didn’t want to find out what it was that they might have to handle in a PR kind of fashion. One of the interesting things about Viagra, from this point of view, is that it does mark a point where companies have changed. By marketing a drug like this, they can expect that some people will be keen to use it. But they can also assume that if we don’t use it then at least we won’t think that the company’s doing something awful and not use any of their other products.Other types of industries—media conglomerates, snack food manufacturers, etc.—do research to find out what the public wants before they initiate their aggressive marketing campaigns. Before drugs are actually made, do pharmaceutical companies send their liaisons into the world to find out what kinds of problems people want fixed? How do pharmaceutical companies convince us that they have the answer for everything?
I get at least a call a month from one agency or another that works for the major pharmaceutical companies asking me if I’d like to be surveyed on issues related to the antidepressants or the anti-psychotic medications I write about. But I think you can see this happening very clearly in other contexts. For instance, there have been a huge number of articles in Newsweek, Time, and the National Enquirer recently that say that people in the West have become too heavy. These magazines describe obesity as a key illness; if we just treat it and get people down to a reasonable weight, we won’t get all of the other problems that come from being overweight and we’ll save billions per year. We’ve seen these articles before, especially during the last few years when companies have had products close to the marketplace that will produce weight loss. You see articles appear in the mainstream media; you see programs about the issues appear on television. We get acculturated to the idea that obesity is a disease that needs treatment. The idea that obesity is the result of your particular lifestyle is one that gets played down in all of these articles. The mainstream media might pay lip service to it—they might say, “Well, of course, you will need to take our drugs and you will have to alter the lifestyle”—but this is against the background of assuming that people will be keen to have a pill that saves them from doing the hard work.Whenever I’ve traveled and spoken with people about weight loss pills, or drugs like Prozac or Zoloft, the response is always, “I don’t know anyone here who takes those. That’s a very American thing.” To what degree is the attitude you’ve described—“I have a chronic illness, and this pill is going to save me from myself or my heredity”—an American idea as opposed to a generally Western idea?
I don’t think so. From a European point of view, and I think there is some evidence to back this up, people in the United States people have greater faith in the latest high-tech medical procedure, whether it is Prozac or Zoloft or an MRI scanner. These things get picked up more quickly in the US than they do in Europe. But I think what you’re talking about here is human nature. It isn’t even particularly Western human nature. Once techniques like cosmetic surgery get fairly reliable, they might get picked up first in the US but they’ll get picked up pretty quickly in the rest of the Western world and pretty quickly worldwide where people can afford to use them.
I think the key issue is whether a technique is going to be reliable or not. Generally, when companies feel that a drug like Viagra can very reliably give people the response that they want, then they can begin to talk about it as a cosmetic or lifestyle-enhancing agent. When a treatment or agent does not deliver a highly reliable response, then companies have much greater recourse to a disease model. The disease model helps companies over this issue about how reliable the treatments is. If you’re treating someone’s condition as a “mood disorder,” people don’t hold you to the standard risks for the treatment that you’d be held to if you were offering them a drug for lifestyle enhancement. They would say, “If you’re offering to sell me this thing that will make me Super-Me, then I want it to be fairly risk-free.”The phrase “lifestyle drug” seems to be such an affluent, First World concept. To what degree is this focus on “lifestyle” a Western one, even if it does get adapted in particular contexts around the world?
I don’t think it’s a very Western thing; I think it’s human nature. Drugs like Viagra sell very well even in poor countries. But the concept of “lifestyle drugs” certainly began in the West. One of the best instances, at least from my point of view, is the case of the oral contraceptive. Growing up in Ireland during the 1960s as I did, when people began to use these kinds of drugs for the first time, the Irish Catholic response to them was, “You will be alienated from your true self if you take a drug like this which is clearly artificial.” By the 1980s, by contrast, the response would have been more like, “If you’re not prepared to take drugs like this, there must be something odd about you; you must be neurotic or alienated from your true self.”
When drugs become reliable, our understanding and how we see ourselves are transformed. Things can move from being a sin just a few years beforehand to being something that is readily embraced by most people only a few years later. I think a very similar fate does wait in store for us with regard to drugs that act on the mind. Many people feel that the prospect of a drug that makes them compete slightly better in the marketplace sounds good, but they’re not sure if it’s going to be the “real them” that’s doing the competing. It may be equally true that many people believe that they have to have drugs in order to compete in the marketplace. Then we’ll all get into a frame of mind rather quickly that says that this is a reasonable thing to do, and we will all change. We can’t afford to differ too much from the rest of the people with whom we live, and we will see it as a fairly normal and natural thing to do.We hear about “super drugs” that are going to be ten times more potent now that pharmaceutical companies are working with molecular biologists to develop drugs that target certain chemical receptors in the brain. Are we on the verge of seeing a brand new class of pharmaceuticals that we had never anticipated before, or are we going to see longer lasting versions of the same drugs?
At the moment, there are no great prospects for breakthrough drugs in the near future. We’re still at a point where, if there are going to be breakthroughs, then they’re going to happen purely by chance. They’re not going to happen because companies have worked out what they want to do. It’s going to happen rather like Viagra, where a drug that was initially developed for the heart will be found to produce other results instead. That’s still the point we’re at, so it’s very difficult to say what’s going to happen in the next five or ten years.The philosophical basis of many of these drugs is that it promotes a particular version of self-hood, an individuated self that is distinguished from the collective or group. How will societies be transformed as a result of drugs designed to alter or reaffirm the individual self?
From the point of view of most pharmaceutical companies, the people in the mid-to-late 1980s who had nervous problems looked slightly more anxious than they do today. During the 1990s, with the rise of the SSRI [Selective Serotonin Reuptake Inhibitor] drugs like Prozac, many of these same people were seen as clinically depressed rather than clinically anxious. And now, post-September 11, many of these companies are probably back in the business of trying to market SSRIs as anxiolytics, drugs that relieve anxiety. Companies seem to be able to mold both the public mind and the professional mind very efficiently.
If we can be persuaded that someone who uses Valium one year should become a Prozac user a few years later, and if we can then be re-persuaded that Prozac users really should be Valium users all the time, then certain Western propaganda of this type will be influential if companies apply the same kinds of approaches in China, India, and other parts of the world. They are going to shape culture there significantly just as they have done here.In the 1990s, the marketing of SSRIs for anxiety disorders seemed concurrent with the marketing of homeopathic remedies for anxiety such as St. John’s Wort. Why do you think those two treatments rose to popular consumption at approximately the same time, and how do they make different appeals to different sensibilities?
I think that, in general, people have trusted the medicines that they can get their hands on and take themselves more than they trust the people who dispense them. We believe that the various herbs we’ve had for millennia did work, and they often did work in the sense that they caused us to be purged or pass water or whatever. Of course, the fact that these things often didn’t help us in any other sense is a slightly different issue.
There’s been a bit of a crisis with the new drugs we’ve had since World War II. Before the war, when you could get barbiturates, amphetamines, or antibiotics by prescription from the pharmacy yourself. After World War II, you could only get them through a physician. If you went to your physician before World War Two you paid for your own health care, and you knew that you didn’t have to take physician’s advice and you could go and see someone else. Or, if you thought that the pills that were prescribed to you were useful, you could get them yourself without having to go back to the physician. It was a totally different kind of patient-physician relationship than the one we have now with managed care companies. People are a lot more dependent on physicians now, and many people aren’t comfortable with that. We’re often left feeling morally wrong if we don’t do just as we’re told.
An awful lot of the frustration with health care now has to do with just this: patients have become, in a very real sense, hostages in ways that they weren’t before. People weren’t treated like addicts in the past. And physicians have become prescribers in a way that they weren’t before. They’ve often failed to recognize the dynamics of what happens when people come for treatment. And while scientists have become very good at assembling evidence on the efficacy of pills, physicians haven’t made the same developments in being able to listen to patients and make sure that they’re on the same wavelength. Now it’s done much more according to algorithms and protocols; there’s very little sensitivity in the interchanges between the physician and the person coming to see them. People have a legitimate fear now that physicians are only offering them certain drugs because a representative visited the doctor’s office from one of the pharmaceutical companies shortly beforehand. They feel vulnerable that they’re getting this pill only because the doctor is on his way to some “conference” in the Caribbean.Speaking of vulnerable communities, a topic close to your heart is the use of anti-anxiety medications like Ritalin among children. How does the widespread use of such drugs bode for future generations and future configurations of community?
I think this is very worrying, and I don’t think we know the answers yet. There has been an increasing use of both Ritalin-type drugs and the SSRIs—Prozac, Zoloft, Paxil, etc.—among children. People’s usual response to this is, “Well, it’s awful to hear that they give these drugs to children when they haven’t tested them out on children.” But in actual fact it’s almost worse if they give these drugs to children after testing them out. Testing doesn’t give us the basis to give drugs to children; it produces the basis for pharmaceutical companies to vigorously claim that their drugs should be given to children.
However bad the problem has been up to this, we probably should recognize that we’ve come from a position where we under-treated children before. We may be overshooting the mark now, but with pharmaceutical companies like GlaxoSmithKline doing trials with Paxil on children, or Pfizer doing trials with Zoloft on children, what we’ll get is not so much good scientific evidence that these drugs should be used for children but actually intense promotional campaigns that will change the whole culture of giving drugs to children. Whatever taboos have held us back up to this point are at risk of being possibly swept away in the future. We are rapidly getting to the position where we have a generation of children who will have been exposed heavily to these drugs from a fairly young age, whose peer groups will potentially lead them to the use of drugs like Ecstasy.It’s interesting that you made the connection between the use of Ritalin among children and drugs like Ecstasy. Are you suggesting that there’s a causal link where a user moves from one to the other? Isn’t that the kind of anti-drug discourse that we hear when young people are told, “Don’t use marijuana because it will ultimately lead to hardcore drug use”?
I would have thought that if children get put on drugs that act on their minds at a fairly young age and peers see that they’re on these drugs, the general rhetoric that aims at trying to discourage children from taking drugs that we’re not terribly keen for them to have is going to be weakened thereby. It’s hard to see how it wouldn’t be weakened. We’ve got a generation of people who will be exposed to pharmaceuticals of one sort or another in a far more comprehensive way than you or I ever were. What that will mean is hard to know.
David Healy is director of the Department of Psychological Medicine at the University of North Wales, and a visiting professor at the University of Toronto. He is the author of The Antidepressant Era (1997) and The Creation of Psychopharmacology (2002).
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© 2002 Cabinet Magazine