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But something shifts in the perception of antipsychotics during the 1960s and 1970s. Hitherto, antipsychotics had been seen as psychoactive agents: they acted on the central nervous system and produced changes in perception, consciousness and behaviour, much as alcohol or LSD do, irrespective of whether the human subject was deemed to be suffering from a mental disorder or not. But gradually, the sense of what antipsychotics actually did changed. The psychiatric profession began to present them as the psychiatric equivalent of penicillin, a biomedical treatment which addressed an underlying mental abnormality. That is, they corrected a so-called ‘chemical imbalance’. They were no longer drugs, they were cures for a disease.
The transformation of the perceived role and effect of antipsychotics was entwined with the general transformation of psychiatry as a whole. After all, ever since the superintendents of lunatic asylums identified themselves as a profession during the nineteenth century, psychiatry, appearing to be more about explicit social control than medical treatment, had been on the defensive. The use of physical treatments such as electroconvulsive therapy during the interwar years had helped psychiatry position itself closer to mainstream medical institutions, as a means of treatment rather than control – but by the 1940s, as Moncrieff notes, medicine was identified more than anything with drugs (penicillin being the main one). Psychiatry needed its equivalent to antibiotics. Hence the name given to the emerging drugs by Heinz Lehmann in the late 1950s: antipsychotics. ‘Thus the new drugs’, writes Moncrieff, ‘helped bring psychiatry further into line with existing medical practice, and contemporaries expressed their delight that the drugs made “the mental hospital a medical institution in the minds of the public”’.
With the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980 - which purged social psychiatry and psychoanalysis from the annals of psychiatry - the ‘remedicalisation’ of psychiatry, in which discrete disease entities were to be treated with specific interventions, had been secured. Antipsychotics were now to be celebrated as a disease-specific cure, rather than grasped as general psychoactive agents.
If the medicalisation of antipsychotics, their transformation from mind-altering drugs into carefully calibrated treatments for specifically classified mental diseases, provided them with a safe, innocuous aura, then the development of the next generation of antipsychotics during the 1990s - so-called atypicals - allowed their prescription to expand exponentially. The figures are startling. In England in 2010, for instance, there were 7.5million prescriptions issued for antipsychotics, a 61 per cent increase on the figure for 1998. Data from the US suggests a similar increase, with medical consultations involving the prescription of antipsychotics tripling between 1995 and 2006. It should be added that, as US figures from 2008 show, only 51 per cent of prescriptions for older antipsychotics and just 24 per cent for atypicals, involved a diagnosis of schizophrenia. This means that the vast majority of prescriptions are for behavioural problems and mood disorders.
So what is going on? Why are there so many more people being given a diagnosis that demands the prescription of powerful antipsychotics?
Moncrieff is quick to answer: ‘That’s an easy one - it’s the pharmaceutical industry. The new range of antipsychotics started to appear on the market in the 1990s, and the first target was to get the new drugs to replace the old antipsychotics used to treat people with severe disorders like schizophrenia. Once that had been achieved, the pharmaceutical companies started looking for new markets for these drugs. And that is when they started trying to expand the definitions of schizophrenia and psychosis to try to pull more people into the diagnostic ambit of those serious conditions. And this was done partly by the transformation of one diagnosis in particular: bipolar disorder.’
Longish but good article.