CS07-01 - From Psychoanalysis to Pharmacotherapy: 1951–2011

Abstract

In 1951 psychoanalysis dominated psychiatry. Treatment for psychotic patients was in the form of sleep treatment with barbiturates, ECT and insulin coma treatment; depressed patients received amphetamines or opium.

1952/3 saw the first neuroleptics, 1957 the antidepressants and 1968 clozapine. This development allowed effective intervention, many closed wards were opened and the walls surrounding psychiatric hospitals demolished.

In this early phase, drug testing was mainly clinician-led and progress came through observation and serendipity. For example, imipramine was tested as a neuroleptic drug and identified as an antidepressant through clinical observation; the drug company assumed clozapine to be ineffective, and lithium prophylaxis was developed purely by clinicians.

In the 70s all somatic treatments were discredited as inhuman on ideological grounds and psychotherapy recommended for all disorders.

The 90s saw the start of the era of modern atypical neuroleptics and SSRIs; there was no progress in efficacy but unwanted effects decreased.

Regulatory agencies (FDA, EMEA) made placebo-controlled trials mandatory but excluded severe patients, leading to an unjustified generalisation of efficacy from moderate to severe states of disorders.

Today treatment is determined by overwhelming administrative/management demands, which distress and demotivate staff and drive up the costs of care. Several big pharmaceutical companies have reduced their interest in psychiatry.

Nothing will change unless society becomes more positive towards and governments allow greater freedom to psychopharmaceutical research; psychiatrists should take the lead of development again and follow up patients into old age in order to identify, for instance, correlates with dementia and suicide.