Editorial Note: This is part 1 of a lecture given at a British Neuropsychiatric Association meeting in London on February 22 under the heading of Psychopharmacology: 1952 – 2017. The lecture will feature here in 3 posts of which this is the first. Slides 1 -11 can be found HERE.
This picture is taken from a newspaper in 1952. It features Jean Delay wearing navy coat, with Pierre Pichot on his right and Pierre Deniker on his left (Slide 1).
Within the hospital behind them, the ice has just melted. Following the ideas of Henri Laborit, they had been giving chlorpromazine which blocks the body’s responses to being chilled down. The hope was that radical cooling would chill patients out in a way that would be useful in the treatment of nervous problems. This was called Hibernotherapy – which always sounds good to an Irishman.
The nurses observed that neither the ice nor the Irish were needed – chlorpromazine given on its own was a chill pill. The nurses were written out of a script that had Delay and his team discovering the antipsychotic effect of chlorpromazine, the discovery that underpins modern psychiatry.
The photograph has always suggested to me a father after the birth of a first child rushing out to tell the world the good news. But this is far from a spontaneous photograph. There is a rigid hierarchical arrangement here. Delay is distinguished by his navy blue coat, which he and only he wore around the university and hospital ground. When he was later elected to the Académie Française, he would wear the ceremonial sword that went with membership whenever possible. He would have been a Sir in the UK. He is talking to Pichot rather than to Deniker, the discoverer of chlorpromazine because Pichot is, strictly speaking, the second most senior person in the Department.
There are things happening in the background, however, that will change everything. In the course of World War II, psychiatrists in the military have discovered that group therapies can have a dramatic impact on the nervous disorders produced in soldiers by the War. These therapies work best it seems where they involve a dissolution of the hierarchies of both pre War European social life and Army life. The more informal the setting, the better.
The other thing that is happening stems from another war that began in 1914 – a War on Drugs. This began with the Harrison’s Narcotics Act, which made the opiates and cocaine available on prescription-only. In 1951, a Humphrey-Durham Amendment to the 1938 Food Drugs & Cosmetics Act made all the new drugs produced by the post-War pharmaceutical revolution, the new antibiotics, antihypertensives, antipsychotics, antidepressants, anxiolytics and other drugs, available on prescription-only.
One of the consequences of this is that chlorpromazine and the later antidepressants bring about a de-institutionalization of – psychiatrists. Not their patients.
Not everybody is happy with the new arrangement. Many complain that a system designed for addicts is not appropriate for the citizens of a free country.
A combustible set of ingredients has been put in place that will lead to an explosion. It only took 16 years for the explosion to come.
In slide 2, you see Tokyo University on fire. Tokyo sits at the apex of the Japanese hierarchy. The students have occupied the Dept of Psychiatry and stay for ten years. Psychiatric research in Tokyo is brought to a halt. The most powerful psychiatrist in Japan, the professor of psychiatry in Tokyo, Hiroshi Utena, is forced to retire.
Why this only 16 years after chlorpromazine had liberated the insane from their straitjackets? Delay boasted chlorpromazine 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 an antipsychiatry that responded that real straitjackets had simply been replaced for chemical straitjackets – the camisole chimique. The silence within the walls of the asylums is the silence of the cemetery.
A revolution is in progress stemming in great part from the new drugs and the interaction between these drugs and 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 was the discovery of a drug that acted on a disease in order to restore a person to their place in the social order. But out of the same test tubes and laboratories came LSD and the psychedelics, Valium and the benzodiazepines. 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.
By 1968, another drug, the oral contraceptive, had begun to transform the social order by changing relations between the sexes (Slide 3). In 1968, for the first time, the French clothing industry produced more trousers for women than for men. By 1968, feminism had appeared to challenge the colonization of women’s minds by men.
1968 saw the culmination of a project begun by Rousseau and Voltaire, the Enlightenment. This was a project, which supposedly dethroned kings and gods. It claimed that the people should be ruled by the people and that an individual’s place in society should depend on merit. But white middle aged and middle class men were still in control. Women, the young, other ethnic groups had no place — until 1968.
In 1968, antipsychiatrists protested against the colonization of the minds of ethnic groups by white Europeans (Slide 4), the colonisation of the poor by the rich, the colonization of the minds of the young by the old. They castigated the new drugs as a means of controlling the young. Madness was the protest of the colonized.
The anti-psychiatrists had a number of powerful weapons in their armory. One was ECT. As Thomas Szasz put it – what the rack and the stake was to the Inquisition, ECT is to organized psychiatry. Its visibility gave it a pivotal role in the pivotal movie One Flew over the Cuckoo’s Nest (Slide 5).
Another weapon was Tardive dyskinesia. This was first described in 1960. By 1968, it was clear that it was a common and disabling side effect of antipsychotic drugs. It was neither the most common nor the most disabling but it was the most visible (Slide 6).
The response from much of psychiatry was the same response as from psychoanalysts to criticism against psychotherapy. When the treatment failed to work, they claimed it was the disease, not the treatment that was at fault. Similarly psychiatry blamed the disease rather than the drugs. Just as we have since done with the SSRIs and suicide.
However, the visibility of Tardive dyskinesia was a real problem. By 1974, SmithKline & French had settled their first legal case for over $1 million. With this settlement, a generation of antipsychotic discovery came to an end. It was to be almost 20 years before any more new antipsychotics emerged (Slide 7).
Meanwhile in 1957, Leo Hollister (slide 8) had run a double-blind placebo-controlled trial of chlorpromazine in patients with no nervous conditions at all, demonstrating that it produced marked physical dependence. There were hopes chlorpromazine might be useful for TB which led to the trial. On stopping after 6 months without benefit, many of those taking it had clear withdrawal problems.
By 1966, a large number of studies had confirmed that there was a marked and severe physical dependence on antipsychotics present in large numbers of people taking them, even at low doses for a short period of time. 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 post-discontinuation changes as long lasting – as in Tardive Dyskinesia – as the changes underpinning current disease models of addiction.
But the recognition of antipsychotic and antidepressant 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 categorize as problematic and dependence producing any drugs, which subverted the social order.
This political rather than scientific decision set up a crisis 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).
Another problem was that while the antipsychotics did help restore people to life outside the asylum, the drugs were also used for the purposes of control. In Britain today we detain people at 3 times greater rate than 60 years ago. We admit people at a 15 times greater rate than 60 years ago. On average, patients are spending a longer time in service beds than ever before in history. New conditions such as personality disorders are being admitted to hospital and the management of violence and social problems has become 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.
This is not what happens when treatments work. In the case of TB and GPI, the beds closed and the staff were redeployed.
This all combined to lead to the greatest possible symbol for the times. On the next slide, you can see the protests in Paris – the epicenter f the 1968 Revolution. The students are on the march. Without knowing the story you already know where they are heading. Their march takes them to the office of Jean Delay, which they ransacked. Delay doesn’t retire immediately but he is a broken man. He has no sympathy for the new world, in which students can expect to address their professors in informal terms (Slide 11).Share this:
Copyright © Data Based Medicine Americas Ltd.
This is not quite what happens when ‘treatments work’
‘transforming social order’
This is the anniversary of this article, a latter day eulogy to Tweeting While Psychiatry Burns but without addressing the ‘Delay’ – a remarkable history with pictures, Part 1.
EXCLUSIVE: How Big Pharma greed is killing tens of thousands around the world: Patients are over-medicated and often given profitable drugs with ‘little proven benefits,’ leading doctors warn
Queen’s former doctor, Sir Richard Thompson, has backed new campaign
Experts calling for urgent public enquiry into drugs firms’ ‘murky’ practices
They say too much medicine is doing more harm than good worldwide
And claim many drugs such as statins are less effective than thought
By Anna Hodgekiss for MailOnline and Ben Spencer Medical Correspondent For The Daily Mail
Published: 22:00, 23 February 2016 | Updated: 11:54, 24 February 2016
THE INDUSTRY’S RESPONSE
A spokesman for the Association of the British Pharmaceutical Industry said: ‘All medicines undergo rigorous testing for quality, safety and efficacy by global regulators.
‘The data is also subject to continuous scrutiny during trials, once licensed and throughout the life of the medicine, including after a patent has expired.’
The spokesman added: ‘The assessment of a medicine – the benefits and risks it brings to patients as well as the value it provides to healthcare – is an ongoing process.
‘Innovating companies discover and develop new uses for these medicines over the life of these products, and regulators and health technology assessors continue to update their assessments based on new information.
‘None of these procedures are “weak” or “murky” but by and large published for public scrutiny.’
‘However, we recognise that the discussion on the evaluation of medicines is timely, and we were pleased to contribute together with many other stakeholders to the “Evaluating Evidence” policy programme of the Academy of Medical Sciences.
‘This dialogue is critical to achieve a shared constructive and progressive framework for the assessment of medicines.’
A spokesman for NHS England last night declined to comment on the allegations.
we can draw a parallel from David’s Magnificent X1 to these Magnificent 11 ..
B.C. firm reaches $6.2M Paxil settlement in class action against GlaxoSmithKline
By The Canadian Press
Wed., March 1, 2017
GlaxoSmithKline Inc. says it has agreed in principle to settle the lawsuit but it does not admit to any liability or wrongdoing.
Moms reach $6.2m settlement over claims that anti-depressant caused kids’ heart problems
In an email, GlaxoSmithKline said that despite the settlement in principle, it does not admit to any liability or wrongdoing but has agreed to resolve the class action case to avoid the time and expense associated with a trial and subsequent steps in the proceedings.
“We continue to be of the view that the scientific evidence does not establish that exposure to Paxil during pregnancy causes cardiovascular birth defects.
“Patient safety is our highest concern and we continue to believe that the company provided accurate and updated information in relation to Paxil to regulators, and communicated important safety information to regulatory agencies, the scientific community and healthcare professionals.”