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Before Prozac: The Troubled History of Mood Disorders in Psychiatry
Psychiatry today is a barren tundra, writes medical historian Edward Shorter, where drugs that don't work are used to treat diseases that don't exist. In this provocative volume, Shorter illuminates this dismal landscape, in a revealing account of why psychiatry is "losing ground" in the struggle to treat depression.
Naturally, the book looks at such culprits as the pharmaceutical industry, which is not inclined to market drugs once the patent expires, leading to the endless introduction of new--but not necessarily better--drugs. But the heart of the book focuses on an unexpected the FDA, the very agency charged with ensuring drug safety and effectiveness. Shorter describes how the FDA permits companies to test new products only against placebo. If you can beat sugar pills, you get your drug licensed, whether or not it is actually better than (or even as good as) current medications, thus sweeping from the shelves drugs that may be superior but have lost patent protection. The book also examines the FDA's early power struggles against the drug industry, an influence-grab that had little to do with science, and which left barbiturates, opiates, and amphetamines all underprescribed, despite the fact that under careful supervision they are better at treating depression, with fewer side
effects, than the newer drugs in the Prozac family. Shorter also castigates academia, showing how two forms of depression, melancholia and nonmelancholia--"as different from each other as chalk and cheese"--became squeezed into one dubious classification, major depression, which was essentially a political artifact born of academic infighting.
An astonishing and troubling look at modern psychiatry, Losing Ground is a book that is sure to spark controversy for years to come.
Naturally, the book looks at such culprits as the pharmaceutical industry, which is not inclined to market drugs once the patent expires, leading to the endless introduction of new--but not necessarily better--drugs. But the heart of the book focuses on an unexpected the FDA, the very agency charged with ensuring drug safety and effectiveness. Shorter describes how the FDA permits companies to test new products only against placebo. If you can beat sugar pills, you get your drug licensed, whether or not it is actually better than (or even as good as) current medications, thus sweeping from the shelves drugs that may be superior but have lost patent protection. The book also examines the FDA's early power struggles against the drug industry, an influence-grab that had little to do with science, and which left barbiturates, opiates, and amphetamines all underprescribed, despite the fact that under careful supervision they are better at treating depression, with fewer side
effects, than the newer drugs in the Prozac family. Shorter also castigates academia, showing how two forms of depression, melancholia and nonmelancholia--"as different from each other as chalk and cheese"--became squeezed into one dubious classification, major depression, which was essentially a political artifact born of academic infighting.
An astonishing and troubling look at modern psychiatry, Losing Ground is a book that is sure to spark controversy for years to come.
304 pages, Hardcover
First published October 28, 2008
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Displaying 1 - 6 of 6 reviews
May 26, 2017
Medical historian Edward Shorter notes that drugs are labeled for marketing and to satisfy government regulation, not for medical usefulness. In Before Prozac he argues that this is why no progress has been made in psychiatric treatment since the 1950s.
Shorter believes old drugs—amphetamines and barbiturates, tranquilizers such as Librium and Valium, antidepressants such as Marsilid, and antipsychotics such as Thorazine—were far more effective than anything available today. So what happened? Why did all those great drugs disappear?
Some went off patent and became unprofitable, but according to Shorter, many were regulated out of existence by a power-crazed Food and Drug Administration (FDA), leaving, in his view, only useless antidepressants such as Prozac.
The whole idea of mood disorders is suspect, he believes. They are defined by the drugs designed to treat them. Thus, when drugs disappear, the disorders they treat also disappear (e.g., “nerves,” “melancholy”—nobody has those anymore). When new drugs are produced (such as Prozac), new disorders are invented to fit the new medications (e.g., “major depression”).
The main villain in his story is the FDA. One might think its purpose is to prevent drug companies from marketing miracle cure-alls, like the patent medicines of the 19th century. But Shorter claims their motivation is really bureaucratic self-aggrandizement—FDA officials drunk with power are set on humbling the mighty pharmaceutical industry by disallowing their most profitable drugs. Why? Because they can. Control of the label means control of the drug, and to satisfy these regulators, the field of psychiatric drugs became increasingly defined by the “antidepressant” because that’s what the FDA believed in.
But Shorter believes that the only effective treatment for depression is ECT (electro-convulsive shock therapy). “Electroconvulsive (‘shock’) therapy, originated in 1938, remains the most effective treatment of serious, melancholic depression” (p. 48). This book was partially funded by Max Fink, a prominent psychiatric researcher and author, well-known advocate for ECT and the founder of the Journal of ECT, in which Shorter occasionally publishes.
Naturally then, the author has a dim view of SSRI antidepressants like Prozac and the FDA which—in his view—forced the pharmaceutical industry to produce them to the virtual exclusion of all else. His thesis seems to be that while melancholic depression is a particular biological disorder best treated by ECT, everyone has been deluded by the DSM, the FDA, and big pharma into thinking that depression is a diffuse category of mood disorders for which SSRIs are the best treatment, even though they are based on a false theory and are no more effective than placebos.
In my reading, Shorter fails to make a convincing case that he is right and everybody else is wrong. That said, this history of psychopharmacology in the United States since 1938 is engagingly written and informative. Because Before Prozac is not an impartial history, I recommend it only to well-informed mental health professionals and for students only in the context of a broader discussion.
Shorter believes old drugs—amphetamines and barbiturates, tranquilizers such as Librium and Valium, antidepressants such as Marsilid, and antipsychotics such as Thorazine—were far more effective than anything available today. So what happened? Why did all those great drugs disappear?
Some went off patent and became unprofitable, but according to Shorter, many were regulated out of existence by a power-crazed Food and Drug Administration (FDA), leaving, in his view, only useless antidepressants such as Prozac.
The whole idea of mood disorders is suspect, he believes. They are defined by the drugs designed to treat them. Thus, when drugs disappear, the disorders they treat also disappear (e.g., “nerves,” “melancholy”—nobody has those anymore). When new drugs are produced (such as Prozac), new disorders are invented to fit the new medications (e.g., “major depression”).
The main villain in his story is the FDA. One might think its purpose is to prevent drug companies from marketing miracle cure-alls, like the patent medicines of the 19th century. But Shorter claims their motivation is really bureaucratic self-aggrandizement—FDA officials drunk with power are set on humbling the mighty pharmaceutical industry by disallowing their most profitable drugs. Why? Because they can. Control of the label means control of the drug, and to satisfy these regulators, the field of psychiatric drugs became increasingly defined by the “antidepressant” because that’s what the FDA believed in.
But Shorter believes that the only effective treatment for depression is ECT (electro-convulsive shock therapy). “Electroconvulsive (‘shock’) therapy, originated in 1938, remains the most effective treatment of serious, melancholic depression” (p. 48). This book was partially funded by Max Fink, a prominent psychiatric researcher and author, well-known advocate for ECT and the founder of the Journal of ECT, in which Shorter occasionally publishes.
Naturally then, the author has a dim view of SSRI antidepressants like Prozac and the FDA which—in his view—forced the pharmaceutical industry to produce them to the virtual exclusion of all else. His thesis seems to be that while melancholic depression is a particular biological disorder best treated by ECT, everyone has been deluded by the DSM, the FDA, and big pharma into thinking that depression is a diffuse category of mood disorders for which SSRIs are the best treatment, even though they are based on a false theory and are no more effective than placebos.
In my reading, Shorter fails to make a convincing case that he is right and everybody else is wrong. That said, this history of psychopharmacology in the United States since 1938 is engagingly written and informative. Because Before Prozac is not an impartial history, I recommend it only to well-informed mental health professionals and for students only in the context of a broader discussion.
October 3, 2014
this book is awesome. i finished it in one sitting- i could not put it down. it's at once funny, optimistic, disturbing, and the rage of the author is infectious as well as cathartic. i want to read everything else by edward shorter. he is the martin luther of pharmacotherapy and it is wonderful.
January 22, 2018
This book has Shorter's trademark strengths and weaknesses. The strengths are good research, readability, clear argumentation.
But: there's also ill-supported idiosyncratic opinions pronounced with an air of authority as if they were unquestionable. Also gratuitous swipes at psychoanalysis, which he blames (again) for retarding biological psychiatry, even though he himself provides examples of analysts who were interested in trying drugs.
He believes the hype over SSRIs has obscured the value of older antidepressants that worked better and were at least as safe. It's definitely true that the side effect profile of the SSRIs was presented in an idealized light when they were first introduced. I agree they likely do not represent an improvement in safety. That the older drugs were more effective? He doesn't really show it. What he shows is that some psychiatrists, the ones he sides with, think so. He bases the case for their efficacy on clinical experience, not trials, but then bases the case for the inefficacy of SSRIs on trials. I agree that RCTs are not the only valid measure of a drug. But you can't use different kinds of evidence for the two types of drugs and confidently claim the new ones are worse. He says the state of mood disorders psychiatry right now is "complete bankruptcy." Really, complete?
But: there's also ill-supported idiosyncratic opinions pronounced with an air of authority as if they were unquestionable. Also gratuitous swipes at psychoanalysis, which he blames (again) for retarding biological psychiatry, even though he himself provides examples of analysts who were interested in trying drugs.
He believes the hype over SSRIs has obscured the value of older antidepressants that worked better and were at least as safe. It's definitely true that the side effect profile of the SSRIs was presented in an idealized light when they were first introduced. I agree they likely do not represent an improvement in safety. That the older drugs were more effective? He doesn't really show it. What he shows is that some psychiatrists, the ones he sides with, think so. He bases the case for their efficacy on clinical experience, not trials, but then bases the case for the inefficacy of SSRIs on trials. I agree that RCTs are not the only valid measure of a drug. But you can't use different kinds of evidence for the two types of drugs and confidently claim the new ones are worse. He says the state of mood disorders psychiatry right now is "complete bankruptcy." Really, complete?
October 21, 2012
I borrowed this book from a person I have heard is an excellent psychiatrist. The book is very challenging in what it says about current treatments for mood disorders. Shorter has an analytical mind which suits the subject matter - the state of play re: medications for mood disorders (e.g. clinical depression and bipolar disorders). At one point he challenges the diagnoses themselves, suggesting in fact most mental illness is a forms of mood disorder. He points out how the construction and presentation of evidence about psychopharmaceuticals has likely led us away from the most solid and proven treatments for such disorders. At one point in the book the author points out that Lithium, although considered old-fashioned in some circles, is best for preventing relapse in bipolar disorder. When it was mentioned that this fact about Lithium be included on the Depakote label (a competing treatment for the condition), the suggestion was not taken up by the pharmaceutical company marketing the product. There are numerous other insights about the state of play regarding drugs for treating mental illness.
August 19, 2012
The meat, I though: Why don't drug companies and the F.D.A. only put up new drugs against placebo, with no need to show improvement over older drugs. The resulting chemical castaways are forgotten, or ostracized. Yet another part of medicine that needs a rethinking.
easy read considering the topic:)
easy read considering the topic:)
January 29, 2015
Really really interesting... A lecture for all psychiatrist.
For me a confirmation that psychiatry is living a crisis.
We need a revolution...
For me a confirmation that psychiatry is living a crisis.
We need a revolution...
Displaying 1 - 6 of 6 reviews