An Ill For Every Pill

by Theodore Dalrymple (March 2008)

I once had a conversation with an eminent professor, of great and even intimidating erudition (though, of course, erudition is not quite the same thing as talent), about the degree of man’s self-understanding. I maintained that it had not increased in any fundamental way, notwithstanding our startling technological progress, and that, in this respect, the neurosciences were greatly oversold, as in the past physiognomy, phrenology, social Darwinism and other doctrines had been oversold.

This was not to deny, of course, the very real achievements of science, but for the great majority of the time, and for the great majority of people, they were peripheral to the central issues and problems of human existence. As for Darwinian explanations of human conduct, they seemed to me of very limited use and power of illumination. Darwinians could always, often with great and admirable ingenuity, fit anything that actually happened into their explanatory schema, ex post facto; but as to giving us a guide as to how to conduct ourselves in the future, they were practically useless. At the most, theoretical Darwinism might tell us the limits of the possible in human conduct, but in fact most of these limits were already pretty well-known to people of common sense (who may, of course, be not all that common).

Sometimes, people take too many opiates and other addictive meds for their respective medical conditions that they end up becoming dependent on those drugs.

The professor was not surprised by any of this; in effect, he had spent much of his life in a Laputan effort to extract sunbeams out of cucumbers. But he was surprised when I said that in any case I looked forward to man’s complete self-understanding, in the sense of complete neuroscientific knowledge of mentation, with dread and trepidation rather than with eager anticipation: not that I thought that that day was coming any time soon (or ever, in fact).

He asked me the reasons for my dread. I said that the abuse of power that would almost certainly result; and I asked him to imagine an instrument so sensitive that it could ‘read’ human thoughts, and anticipate them. Would he want such an instrument applied to him? Would he wants others, or even a single other person, to know exactly what he was thinking all of the time? It would surely be hellish, and incompatible with normal human relations. This explains why life cannot and ought never to be lived in complete sincerity and honesty, as an open book; disguise, insincerity and hypocrisy are what make life bearable for self-conscious beings like humans. The art of living is in large part that of knowing when and when not to speak one’s mind. Voltaire said that the way to be a bore is to say everything; he might have added that it is also the sure way to be a monster.

We are quite often told, however, that man’s self-understanding is, at long last, just around the corner. We are especially inclined to believe this because it is certainly the case that our science and technology has produced many marvels for us, and we think that self-understanding is a mere matter of the exponential increase in the powers of technology, like that which has taken place in the power of computers. Progress in self-knowledge is inevitable.

In 1993, for example, a psychiatrist called Peter Kramer published a best-selling book entitled Listening to Prozac. In this book, he suggested that our scientific understanding of brain chemistry has advanced so far - as witnessed by the development of the serotonin reuptake inhibitor, fluoxetine, Prozac - that we would soon be able to make up our personalities and characters (there is an often-neglected difference between the two) much as make-up artists make up the faces of actors in films and on the stage. Dr Kramer quoted cases in the book of people who had taken Prozac and had become better than well. Formerly shy and retiring types became outgoing and boisterous (personally I prefer shy and retiring types, but that is a different question). Yes, soon we could be all we wanted to be, and merely by swallowing a pill!

This was always nonsense, of course, though exactly the kind of nonsense that people wanted to hear because it is only too human to want all our problems and anxieties to disappear with what in effect is a wave of a wand. After all, in the not very distant past people held on to the idea that if only the buried psychological treasure that lay within them could be found, that is to say the repressed trauma that had caused their undesired characteristics and behaviour to develop, with the help of course of a technically-proficient therapist, then the latter would disappear spontaneously, without further effort or ado on their part, and the beautiful real person that laid buried inside them would emerge as a butterfly from a pupa and fly off into the sunshine of eternal happiness.

All this was just as superstitious as magical incantations ever were. The idea that Prozac (and drugs still to come) would solve all of life’s little problems was no more realistic than the following, which I found in John Aubrey’s Miscellanies upon the Following Subjects: Omens, Dreams, Apparitions, Voices, Impulses, Knockings, Blows Invisible, Prophesies etc., published first in 1696 (my edition is the second, of 1721): To cure the Biting of a Mad Dog, Write these Words in Paper, Viz.: Rebus Rubus Epitescum, and give it to the Party, or Beast bit, to eat in Bread. A Gentleman of good Quality, and a sober grave Person, did affirm, that this Receipt never fails.

From the very first, Prozac was presented by its praise-singers as a fundamental advance, when it was perfectly obvious that it was nothing of the sort. It was no more effective than antidepressants which had been known since the early 1960s, though its side-effects were different and, for many people (though not all), more tolerable. The neurochemical theory that accounted for its very limited superiority over placebo in serious cases of depression was crude and reductive, to say the least.

Unfortunately, Prozac came on to the market just at the time when another product of a rather crude and reductive theory, or attitude, the Diagnostic and Statistic Manual of the American Psychiatric Association, became the object of almost universal superstitious awe and veneration. Here I rely on a brilliant book published last year by two professors of sociology, Allan V Horwitz and Jerome C Wakefield, entitled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. They point out what should have been obvious to any person with the most minimal knowledge of human nature, that the definition of depression in that manual is complete disassociated human mood from the actual lived circumstances in which it was experienced. It was sufficient to be diagnosed from depression to have a certain number of symptoms for a certain length of time: two whole weeks!

This not only was a retrogression in our understanding of human life by comparison with that held in the past by almost everyone, including psychiatrists, but had the effect of turning practically the whole of the human race into psychiatric casualties. The World Health Organization has recently stated that depression is the condition which imposes the second greatest burden of illness and disability on mankind, to believe which requires more suspension of critical faculties than to believe that Peter Pan is a real person, or that Father Christmas is currently in Lapland preparing for his next forays down our chimneys.

Now if people are depressed, it follows that what they need is Prozac, or a drug very similar to it. And of course, since one might define mankind as the only creature that is susceptible to the placebo effect, in many cases the drug will have worked (it is inevitable that someone will write to say, ‘Well, it worked for me, and that’s enough,’ just as it probably was enough for the Gentleman of good Quality, a sober grave Person). On the other hand, although the positive effects of these drugs are largely imaginary, many of their side-effects are only too real. Indeed, it is the reality of these side effects that persuades people that the therapeutic effects must be real too: for it is a deeply-ingrained belief in most humans that effective medicine must be nasty to take.

The beneficial effects of drugs such as Prozac were grossly overestimated because the results of trials in which they proved not to be effective went unpublished, partly because negative results are uninteresting, undramatic and unexciting, and no doubt partly because of deliberate suppression. At any rate there is no evidence, and never has been any evidence, that Prozac favourably affects ordinary unhappiness. And if mass prescription comes, can class action be far behind?

Does it really matter, though, in any wider sense, that huge numbers of people have been given drugs that don’t work to cure a condition that does not exist? (Let us leave aside the question of expense.) As we have seen, there are sometimes matters more important than intellectual honesty and consistency; and if in fact large numbers of them have benefited from a placebo response, why should we worry? As the late Deng Xiao Ping said, what does it matter if a cat is black or white, so long as it catches mice?

To quote another luminary, Albert Einstein, not everything that is measurable is important, and not everything that is important is measurable. I think there is an intangible harm to seeing life as a technical problem to be solved by neurochemical manipulation, namely that is unrealistic, crude, uncivilised and ultimately cruel. It induces a kind of wilful blindness in people, who see their own disastrous decisions as being the result of disordered chemistry rather than as that of inadequate thought and character, and places the responsibility on others - particularly, of course the medical profession - to repair the damage and prevent it from recurring.

Although there has recently been an upsurge in anti-religious writing, the scientistic view of human behaviour, that it is all a matter of too much or two little serotonin, represents a decline in understanding by comparison with that of the best divines (and I say this as an unreligious person). I wish I had a hundred dollars for every time I had overheard people saying to each other that their brains were chemically unbalanced, which explains why their lives were less than fulfilled.

The combination of the DSM and the availability of many different antidepressants has turned many doctors into check-list clerks: a sufficient score indicates treatment with Prozac. Judgement, let alone attempts at sympathetic understanding - which is not necessarily the same as complete agreement with the patient’s view of things - and compassion, are rendered completely redundant. And since a lesser number of symptoms than that required by the checklist might indicate depression of lesser severity, and it is best to nip depression in the bud before it develops into a more serious form, almost all degrees of expressed dissatisfaction, and indeed some that are not expressed, end up being treated with the pills. The unhappiness of their patients now acts on doctors as the ringing of the bell once acted on Pavlov’s dogs.

The American doctor and writer Oliver Wendell Holmes (whose son was the famous judge, and who was himself not only one of the first people to give anaesthesia but also one of the first to appreciate the infective nature, spread by doctors, of childbirth fever) once said that if the whole of the pharmacopoiea were thrown into the sea it would be the better for man but the worse for the fishes. I don’t think this is true any more, but if all the Prozac in the world were thrown into the sea, I doubt that man would be more miserable and the fishes happier.

Not that I expect mankind to have learnt anything from the wretched Prozac story. In a few years’ time, if not before, someone will come forward with claims that he has found the technical solution to man’s dissatisfaction with his existence, will be believed for a time, and possibly make a fortune. Illusion and disillusion spring eternal in the human breast.

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