The ethical pharmaceutical industry developed in the early years of the 20th century. These and subsequent decades were a time of remarkable improvement in the health of people in the industrial democracies. The infant mortality rate fell, life expectancy increased and a number of scourges, such as tuberculosis and diphtheria, were eradicated. To a large extent technological developments in medicine – and perhaps pharmaceutical developments in particular – have been credited in the popular mind with bringing about these improvements.
The reality, as Thomas McKeown has demonstrated, 28 was more complex. The drop in mortality rate from a variety of infectious diseases antedated the development of antibiotics, vaccines or any specific drug therapies. It resulted in the main from improved nutrition, the alleviation of overcrowding and public works programmes such as the provision of better sanitation. The increasing development of ‘high tech’ medicine, which has grown more spectacular with every decade since the Second World War, has done little to extend the basic improvements in health care brought about at the turn of the 20th century.
Public perceptions of progress in psychiatry are the same as perceptions for other medical developments. The introduction of antipsychotics and antidepressants is credited with bringing about our current programme of emptying and closing large mental hospitals, by enabling the treatment of psychological disorders in the community. The reality is more complex. The closure of the large hospitals owes a great deal to administrative changes. Until the early 1950s many of the large asylums followed a policy of lumping patients together in wards regardless of diagnosis. 29 Substantial improvements were brought about simply by separating the mentally ill from the mentally handicapped, older subjects from younger individuals, chronic patients from those with acute disturbances, and milder problems from more severe ones. This led to the development of a wider range of treatment strategies for specific problems and a change in morale within the psychiatric services, to which the advent of chlorpromazine contributed. 9 In contrast, in Japan the advent of chlorpromazine led to a quadrupling of the numbers in hospital beds, indicating that there was no necessary link between chlorpromazine and de-institutionalisation.
What else of a non-specific or ‘low tech’ nature can be done or needs to be done now? There is a range of issues. Among the most important are the questions of child abuse, both sexual and physical, but also mental torture, psychological cruelty and domestic violence.30 and 31 It increasingly appears that programmes aimed at prevention of such abuses would lead to a reduction in morbidity in later life. It also appears that hi-tech medicine is becoming a hazard in its own right.
The process of randomised, placebo-controlled trials that has been used to show that specific high-tech approaches work for certain conditions also reveals that non-specific treatments work. In trials of antidepressants, where 50% respond to the antidepressant, up to 40% respond to a placebo. What this means in practice is that, unlike the treatment of infection with an antibiotic, when it comes to the treatment of nervous conditions neither the antipsychotics nor antidepressants are so specific that they will knock out the ‘psychic infection’ that an individual has regardless of the circumstances in which treatment is given. The rapport that patients have with those looking after them plays a big part in the likelihood of response to treatment and in the quality of that response.
Bamboozled by the evidence that antidepressants can be shown to add something over and above the benefits that can be obtained from a good-quality therapeutic relationship, we are at risk of forgetting that without the bedrock of a good-quality relationship they may not work at all. The psychotropic drugs should have made psychopharmacotherapy possible; the risk is that they will result in the staffing of the mental health service with psychopharmacological technicians. And indeed physicians do seem to have become prescribers, who are increasingly insensitive to the dynamics of the relationships in which prescribing takes place. Physicians seem on their way to becoming ‘pharmacologists’.
Other non-specific developments that might be as therapeutic, if not more so, than the specific benefits of drug treatment include the provision of detailed information regarding drug therapies to those who take psychotropic medicines. As this book illustrates, the harmful effects of such drugs on a person’s life may entirely outweigh any benefits they could have conferred if used judiciously. Intuitively it would seem that enabling individuals to take control of their own lives in this way and to make their own decisions would be a good thing. There is considerable philosophical justification for such a position. 32 However, this runs counter to the prevailing mechanical models in medicine that underpin current drug company research and business programmes. It remains to be seen what the outcome of this potential clash will be.
HEALTH CARE OR HEALTH PRODUCTS LTD?
The landscape of health has been completely transformed in the past 50 years. Where once we consulted doctors and didn’t dare question them, or if we did the response was likely to be that they would be prepared to discuss matters if we came back with a medical training, controlled trials put evidence on benefits and risks out into the public domain and enabled people to question their doctors. Medical people had to descend from a pedestal and get engaged in collaborating with their patients in a new way – as guides or experts. This gave rise to a language of choice and rights, and terms such as ‘consumers’ and ‘clients’ replaced the older ‘patients’. But these new data and processes also gave rise to what is increasingly becoming a market in health products, of which pharmaceuticals are the most obvious examples but where entire services are in fact being packaged and managed as products. And to sell the product, the adverts for drugs and mental health services promise what adverts for automobiles and shampoos once promised – your life will be enhanced if you purchase our product.
This is a long way from health care in which nurses, doctors and others tried, with those of us who are suffering, often against the odds, to produce health. The term ‘patient’ is a much better word for this – referring as it does to someone who endures. From a caring perspective, it makes as much sense to call a patient a client as it would for a mother to call her child a client or a teacher to call her pupils consumers. From a caring perspective, adverts for insulin that portray patients with diabetes as young and healthy and walking in the mountains are close to offensive. The reality of the illness in clinics is that this disease shortens lives and people have to be taught to prick the side of their finger to get blood samples, because they may need the touch-sensitive pulp of their fingers if they go blind. 33 Adverts for antipsychotics and antidepressants are typically equally divorced from the reality of caring, which rather than delivering cures for the most part involves a myriad of adjustments to cope with the frailties of the human body and mind.
Both those seeking help for mental problems and those whose help they seek in this sense aim at producing as much health as possible out of what are some of humankind’s most debilitating illnesses. But there is an increasing problem for all of us seeking help and those of us who are trying to care in that we are being progressively alienated from any ability to care in this sense. We are encouraged to follow guidelines and protocols rather than listen to our patients and do something that may be individual. The rhetoric may be increasingly about personalised medicine; the practice is increasingly standardised and the outcomes are getting worse rather than better.
We are in a world where health care professionals focus on their own organs and segment risks accordingly. This means that cardiovascular physicians aim at lowering lipid levels and are happy if the drugs they prescribe do this. Even though mortality from non-cardiovascular causes may be increased they do not consider it necessary to inform their patients about this. 34
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