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By Richard Handler

One Step Forward, Two Steps Back

Is psychiatry going backward?

Before Prozac: The Troubled History of Mood Disorders in Psychiatry
Edward Shorter
Oxford University Press. 304 pp. ISBN: 9780195368741

It's now been more than 30 years since the advent of SSRIs like Prozac and its descendants (Zoloft, Luvox, Celexa, Paxil, Lexapro, etc.) triggered what many consider a psychopharmaceutical revolution in psychiatry.
As these medications gained popularity, psychiatry lost its final connections to talk therapy and abandoned the use of an older generation of "ineffective" mood medications. There's only one problem with this widely accepted success story, according to historian Edward Shorter in his new book, Before Prozac: "Most of the antidepressants today don't work very well. That is, in contrast to the 1950s and '60s, when some truly effective medications for mood disorders were available."

Shorter's book is a rip-roaring assault on the practice of modern psychiatry that makes some large claims, the ineffectiveness of the SSRIs not even being the largest. Over the past two decades, he argues, psychiatry actually has gone backward. "Medicine is supposed to make progress, to go forward in scientific terms," he writes, "so that each successive generation knows more and does better than previous generations. But this hasn't occurred by and large in psychiatry, at least not in the diagnosis and treatment of depression and anxiety."

It's Shorter's contention that a host of suitable drugs were developed for depression and anxiety in the 1940s and '50s: the tricyclic antidepressants (the TCAs), like amitriptyline and imipramine. But even effective drugs eventually lose their patents, resulting in the proliferation of generics and an inevitable decline in profits, which is hard on the bottom line of drug companies. Fortunately—at least this is the drug companies' viewpoint—the SSRIs came along to save the day. They were, and still are, touted to be more effective and to have fewer negative side effects—or at least more tolerable ones—than previous drugs. The pharmaceutical companies made billions selling them, abandoning the older drugs that generic firms could manufacture at a fraction of their initial cost. The companies focused on sending reps to shrinks' offices to talk up the benefits of their new products to every doc they could meet, and distributed free samples like candy.

Shorter is certainly not the first critic to draw this picture of the pharmaceutical industry, but he carries it farther. He disputes the idea that patients tolerate the SSRIs better than TCAs and offers quotes from psychiatrists and other citations to back up his claim. He contends that "there has never been a more effective antidepressant drug than imipramine," even though it was first launched in the American market in 1959. He believes that the adverse side effects of SSRIs have been vastly underreported, and that they are much more intrusive than those caused by the older TCAs. "Dear Reader," he writes drolly, "which would you rather have: impotence or [TCA] dry mouth?" Psychiatrists and patients may dispute Shorter's claims of the effectiveness of TCAs, but that doesn't stop his sometimes offhand polemics, buttressed by piles of footnotes.

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