Historians are different – they see the world and its complex relationships through prisms not available to most of us. Psychiatry has, of course, provided meaty flesh for historians and their prisms from both inside and out for most of its existence but I've never been sure how much further they have taken understanding. It's easy to whinge from the side-lines in a way that's not helpful to those trying to get a balanced perspective on their discipline while holding chaos from the door of under-provisioned services.
Professor Shorter is a historian of psychiatry and this work joins a succession of publications trying to find a voice in quite a crowded critical market. As its title suggests, the sweep is broad, seemingly challenging the very validity of one of psychiatry's core interests. But is there substance here?
First, there are some factual errors. Reserpine is not an MAOI but a VMAT2 inhibitor, and the dexamethasone suppression test did not sink under the weight of professional indifference but because of its lack of specificity. And on two occasions Weinberger and colleagues at NIMH get credit for ‘replicating’ Jacobi and Winkler's PEG work on brain structure in schizophrenia of 50 years before when, of course, what they were replicating was Johnstone et al's CAT scan study of 1976. NIMH was not ‘scooped’ by the pre-war Germans but by Northwick Park. This highlights an inevitable American bias, for although Shorter does make reference to some seminal European individuals and developments in psychopharmacology, the overwhelming thrust of this book is towards American institutions and individuals. And, taking a broad overview, the number of his sources is actually rather small, with repetitions of their slants, and the casual reader could be left with the feel of old men at the end of their careers looking back on why things had not worked out the way they wanted.
The author writes in a very readable style but with a folksy nostalgia for times past that to someone who (alas) can claim to have been through part of them seems a bit Proustian. His views on pre-operationalised diagnosis ring only soft bells, while his attachment to ‘catatonia’ as seemingly the only or validatable schizophrenia subtype is perverse for a syndrome now more commonly found in affective disorders. And while the ‘old men’ may still believe they just ‘knew’ when a drug worked and didn't need a trial to tell them – well that, Prof. Shorter, is definitely old men's talk and most, like myself, would prefer to stick with the RCT.
But in a substantial piece of work, at the end of the day such criticisms are minor – no more than ‘over-a-drink’ badinage – for in terms of his targets, Professor Shorter is, in my view, spot on. There are a number, but his list of malfeasances is crowned by the same two that top mine – the deskilling, infantilising impact of DSM and the pernicious influence of pharma marketing.
How I enjoyed his account of the evolution of DSM to its third edition in 1980! When I started in research in the 1970s, we felt fortunate to have at our disposal the newly published St Louis criteria (though I did chuckle at how they came about, a tale told here). The problem researchers had was how to standardise research materials to make findings generalisable to international research communities. The principle was not to use such methods to ‘diagnose’ but to apply them to samples already diagnosed within one's own school of psychiatric practice. It was shown early that around 30% of patients diagnosed clinically as ‘schizophrenic’ would not fulfil the criteria – but that did not mean they did not have disorder within the syndrome. It simply meant that Dr Yamamoto in Tokyo knew what Dr Owens in London was talking about when he used the term ‘schizophrenia’. This was a huge step forward, facilitating enormously the ‘chatter’ of international research. So most of us looked forward to DSM-III, a long-overdue update to a theoretically redundant system and a concerted effort to tackle psychiatry's very soft Achilles’ heal – the poor reliability of diagnosis that the anti-psychiatry movement had so fed off. How disappointed we were to be – not initially perhaps, but within a decade concerns were evident and within two, Paul Mullen and later Nancy Andreasen could point to the ‘unintended consequences’ of a profession increasingly removed from the foundations of one of its core skills – diagnostics. This is a great read and contains material that should be known to all psychiatrists.
Then there's pharma. Professor Shorter doesn't lessen the tension in his bow here either and time and again hits the bull's eye. On the principle of full disclosure, I will admit to an ‘interest’, for while I may not have been what's referred to as a ‘key opinion leader’ (KOL) it might be claimed I was an ‘OL’ before relinquishing pharma involvement (and the ‘nose-cone’ air tickets that went with it) to join the UK and European regulators some 20 years ago. So I can comment with the authority of witness on the accuracy of Shorter's core arguments – can vouch for the insidious and unctuous rise of the marketing folk, the lack of concern within our profession at the real purpose behind the ‘unrestricted educational grant’ and the sad role these have played in determining not just practice but theory itself within our profession. On only one occasion did I give up on trying to get a paper published. Around the millennium, I wrote a piece based on something I had come to know a little about – EPS. My point was that the real-world evidence did not support the notion of newer antipsychotics being fundamentally different in their pharmacology from what had come before. Any EPS advantages lay in how we used these newer drugs, and the ‘atypical’ concept was a myth. I submitted this to nine different journals and was rejected by all, in the process getting the most damning ‘review’ I ever received: ‘How nice to read a scientific paper by someone who writes such good English. Pity about the content!’ (yes, I memorised it). Others tell similar stories in relation to studies now considered seminal but initially deemed unpublishable by a psychiatric orthodoxy frozen solid in the grasp of industry hype.
At least I wrote my own paper, contentless perhaps but well! Another powerful point made here is the damaging impact of the professional medical writer on even the ‘quality’ end of the literature, which has not been highlighted enough. I was once approached by a company to write a review on the EPS data of their drug – but if I was too busy, they could of course arrange for it to be written for me. All I needed to do was approve the content. I thought they were joking but so many others obviously didn't. The modern fascination with publication ‘counts’ obscures the fact that it is simply – let me assure you – impossible to undertake research, teaching and clinical responsibilities – and ‘keep up’ – then publish at the rate some of our ‘opinion leaders’ dazzle us with.
Within these broad points there is certainly more ‘over-a-drink’ debate to be had. For example, I am less ‘anti’ SSRIs than Professor Shorter, who to my mind fails to grasp that the tricyclics of which he, like myself, is a fan are poorly tolerated compounds, a week's supply of which can be lethal. The rise of the SSRIs may have been energised by industry but without that massive safety advantage they would have struggled to reach their current, inappropriately dizzying heights. And I would have approached his work more positively had his title been less attention-grabbing. Personally, the book did not persuade that there is or was an ‘age’ of psychopharmacology and I did not, on completing it, find much to support its putative ‘fall’ as a scientific discipline. I could perhaps have related better to a slight modification: ‘The Rise and Fall of the Age of the Psychopharmacologist’, that inappropriately named ‘expert’ who abandoned ‘psyche’ expertise for a ‘pharmacology’ in which most had few, if any, skills.
On removing this book from its envelope I was amazed that I, of all people, should have been sent such a title to review for this journal. But I thank the editors that they did. There is much in this book to inform all psychiatrists – and who knows, a good deal from which we, as a profession, might actually learn.
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