How Prozac Slew Freud

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Not long ago I was lecturing in my course on medical history about people who had accused themselves of smearing feces on a crucifix or committing some equally sacrilegious act. In fact their beliefs had been delusional. They had done nothing of the kind, but one manifestation of their illness was this untrue self-reproach.

After the lecture an older student, a woman in her thirties, came up to me and said, “I’d like to talk to you.”

 

Not long ago I was lecturing in my course on medical history about people who had accused themselves of smearing feces on a crucifix or committing some equally sacrilegious act. In fact their beliefs had been delusional. They had done nothing of the kind, but one manifestation of their illness was this untrue self-reproach.

After the lecture an older student, a woman in her thirties, came up to me and said, “I’d like to talk to you.”

We went back to my office. She said, “You know those patients you mentioned with that kind of idea? I’ve been having those same thoughts myself.” She had been depressed.

“Are you being treated by someone?” I asked.

She nodded. “I’ve been seeing a psychoanalyst.”

My heart sank. Of all the treatments available for such a complaint, she had chosen the worst.

For her, psychiatric problems meant seeking psychoanalytic help, because she thought the terms were synonymous. Psychiatry, psychoanalysis, psychology—aren’t they really all pretty much the same thing? Millions of people think so.

In fact, psychiatry is the branch of medicine that specializes in diseases of the brain and mind, excluding the obviously organic ones that neurology treats. Psychology is the science of the mind, and psychological treatment consists mainly of psychotherapy. Psychoanalysis is the particular method of psychotherapy developed by Sigmund Freud in turn-of-the-century Vienna, and today it is virtually dead within psychiatry. The average psychiatrist will never ever ask patients about their dreams. Half of all visits to psychiatrists in America now end with the prescription of a psychoactive drug, such as the antianxiety drug Xanax or the antidepressant Prozac. Indeed, the discipline has changed radically in the past thirty years. Not one of the psychiatric verities of a couple of generations back has survived intact.

Few Americans are aware of these changes, yet such is the importance of psychiatric illness that they amount to one of the most important stories of the century. Serious mental illness in American society is literally as common as gallstones. According to the National Center for Health Statistics, five in every thousand Americans will be hospitalized for psychosis every year, almost exactly the same rate as for cholelithiasis.

Among women in Western countries, major depression is by far the commonest illness. According to Harvard’s new School of Public Health Global Burden of Disease study, five of the top ten causes of chronic disease in women are psychiatric. (In addition to depression, they are, in order of frequency, dementia, schizophrenia, manic depression—now called bipolar disorder— and obsessive-compulsive behavior.)

Men aren’t depressed as often as women, but they have the lion’s share of other psychiatric problems. They suffer two to three times as many substance-abuse disorders as do women, and they hold a kind of monopoly on antisocial personality disorder, getting into bar fights and the like.

Altogether, psychiatric problems are just about as common as the common cold, and how they have been confronted over the century is a major story—a heartbreaking one when you consider how such treatment was mishandled in the past, a heroic one when you consider how much better, and with what scientific audacity, we are dispensing it now. We have come a distance in thirty years, but in a sense we have come full circle. We have returned to the turn-of-the-century view of psychiatric diseases as medical problems requiring medical solutions. Only now we have many solutions that work.

From its very beginnings psychiatry has been torn between two visions of mental illness. One stresses the neurosciences, with their interest in brain chemistry, brain anatomy, and medication, seeing the origin of psychic distress in the biology of the cerebral cortex. The other looks to patients’ lives, attributing their symptoms to social problems or personal stresses to which they have adjusted imperfectly. The neuroscience version is usually called “biological” psychiatry; the social-stress version makes great virtue of the “biopsychosocial” model of illness. Yet even though psychiatrists may share both perspectives, when it comes to treating individual patients, the perspectives themselves really are polar opposites. Either one’s depression arises from a biologically influenced imbalance in one’s neurotransmitters, perhaps activated or intensified by stress, or it reflects some psychodynamic process in one’s unconscious mind. It is thus of great importance which vision dominates psychiatry at any given moment.