Becoming Neurochemical Selves

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Becoming Neurochemical Selves

Nikolas Rose

Introduction
How did we become neurochemical selves? How did we come to think about our sadness as a condition called ‘depression’ caused by a chemical imbalance in the brain and amenable to treatment by drugs that would ‘rebalance’ these chemicals? How did we come to experience our worries at home and at work as ‘generalized anxiety disorder’ also caused by a chemical imbalance which can be corrected by drugs? How did we – or at least those of us who live in the United States – come to code children’s inattentiveness, difficulties with organizing tasks, fidgetiness, squirming, excessive talkativity and noisiness, impatience and the like as Attention Deficit Hyperactivity Disorder treatable by amphetamines? How did some of us come to understand changes in mood in the last week of the menstrual cycle - depressed mood, anxiety, emotional lability and decreased interest in activities - as premenstrual dysphoric disorder, treatable with a smaller dose of the very same drug that has become so popular in the treatment of ‘depression’ – fluoxetine hydrochloride? Perhaps some names give a clue. Depression: not so much fluoxetine hydrochloride as Prozac. Generalized Anxiety Disorder: not so much paroxetine as Paxil. ADHD: not methylphenidate or amphetamine/dextroamphetamine but Ritalin and Adderall. Premenstrual dysphoric disorder: not so much fluoxetine hydrochloride (again) but

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Sarafem. And some more names: Prozac and Sarafem: Eli Lilley. Paxil: GlaxoSmithKline. Ritalin: Novartis (Ciba Geigy). Adderall: ShireRichmond. In this paper I want to explore the linkages between the reframing of the self, the emergence of these conditions, the development of these drugs, the marketing of these brands and the strategies of the pharmaceutical companies. These do not just reshape our ways of thinking about and acting upon disorders of thought, mood and conduct. Of course, they have enormous consequences for psychiatry as it is practiced in the psychiatric hospital, for the ‘community psychiatric patient,’ and in the doctors surgery. But they have also impacted on the workplace and the school, the family and the prison – not to mention the bedroom and the sports field. And this recoding of everyday affects and conducts in terms of their neurochemistry is only one element of a mode widespread mutation in which we in the west, most especially in the United States, have come to understand our minds and selves in terms of our brains and bodies. I have started with neurochemistry: the belief that variations in neurochemistry underlie variations in thought, mood and behaviour, and that these can be modulated with drugs. I might have started with brain imaging: the belief that it is now possible to visualise the activities of the living brain as it thinks, desires, feels happy or sad, loves and fears, and hence to distinguish normality from abnormality at the level of patterns of brain activity. Or I might have started with genomics: claims to have mapped precise sequences of bases in specific chromosomal regions that affect our variations in mood, capacity to control our impulses, the types of mental illness we are susceptible to and our personality. But here, I want to start with the pharmaceuticals themselves.1

Psychopharmacological Societies
Over the last half of the twentieth century, health care practices in developed, liberal and democratic societies, notably Europe and the United States became increasingly dependent on commercially produced pharmaceuticals. This is especially true in relation to psychiatry and mental health. We could term these 'psychopharmacological' societies. That is to say, they are societies where the modification of thought, mood and conduct by pharmacological means has become more or less routine. In such societies, in many different contexts, in different ways, in relation to a variety of problems, by doctors, psychiatrists, parents and by ourselves, human subjective capacities have come to be routinely reshaped by psychiatric drugs. Whilst attempts at chemical solutions to psychiatric problems have a long history, the modern era begins in the 1950s for it was at the is point that drugs were formulated and marketed that were not merely sedative but claimed to have a specific effect on particular symptoms of certain

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psychiatric conditions. It is well known that the first widely used psychiatric drug was chlorpromazine, developed from antihistamines by company scientists at the pharmaceutical firm Rhône-Poulenc in the years after the Second World War.2 Two French psychiatrists, Pierre Deniker and Jean Delay, who administered it to a group of psychotically agitated patients at the Hôpital Sainte-Anne in Paris in 1952, are credited with the discovery of its psychiatric effects. It was taken by RhônePoulenc to Canada, and licensed to Smith Kline and French who promoted it heavily in the United States under the name of Thorazine where it spread rapidly through the crowded psychiatric hospitals making them $75m in 1955 alone. It was thought not to be a sedative like barbiturates or chloral, but to act specifically on the symptoms of mental illness. Nonetheless, up to the late 1960s, most psychiatrists thought of it as a general ‘tranquillizer’. It was followed by the development of drugs specifically claiming to treat depression and named ‘anti-depressants’: Geigy’s imipramine (Tofranil) was tested by Ronald Kuhn at the Münsterlingen Hospital near Konstanz during the early 1950s and despite the initial lack of enthusiasm - depression was not seen, at that time, as a major psychiatric problem - Tofranil was launched in 1958 and became established as the first ‘tricyclic’ antidepressant in 1960s – so-called because of its three-ringed chemical structure. It was followed by Merck’s tricyclic, amitryptiline (Elavil) in 1961. Over the same period, other drug companies and psychiatrists were experimenting with other drugs – reserpine, isoniazid, iproniazid (Marsalid) – which would eventually give rise to the influential ‘serotonin hypothesis of depression’ so crucial for the fabrication and marketing of Prozac and its sisters. And, as we shall see, it was also in the 1950s that the pharmaceutical companies developed and marketed drugs for the stresses and strains of everyday life – the compounds that became known as ‘tranquillizers’. Accurate comparative and historical data on psychiatric drug prescribing since the 1950s is not readily available. But some can be found in published sources, and some more is available from commercial organisations that monitor the pharmaceutical industry, notably from the leading organization monitoring the pharmaceutical industry, IMS Health.3 In this paper, I draw upon these different sources of evidence to illustrate some general trends and patterns. Whilst the interpretation of the detailed figures is subject to many qualifications, and actual numbers should be regarded simply as indicative, they are sufficiently robust for these purposes. Over the decade from 1990 to 2000, the growth in the value of sales of psychiatric drugs is constant, yet uneven in different regions of the world (Figure 1): 4 FIGURE 1: Sales of psychiatric drugs 1990-200 in selected regions

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In South America it has grown by 201.1%, in South Africa by 55.9%, and in Pakistan by 137.8%. In the 'more developed' regions, Japan has grown by 49.6% from an initially low base level of sales, in Europe, from a relatively high base, growth has been by 126.1%, and growth in the value of sales in the United States been by a phenomenal 638%. Within these regions, the value of psychiatric drugs dispensed at pharmacies and hospitals as a proportion of total drugs dispensed in this way varies greatly. At the end of the decade in the United States, sales of prescribed psychiatric drugs amounted to almost $19 billion- almost 18% of a total pharmaceutical market of $107 billion,5 while the market in Japan, at $1.36 billion, amounted to less than 3% of a total pharmaceutical market of $49.1 billion.6 Of course, these data on the market for prescription drugs and its growth are affected by the relative costs of the drugs, pricing decisions of manufacturers for particular regions, financial regimes in operation in different national health services, and the availability of certain medications on a non-prescription, over-the-counter basis. Hence financial data does not accurately represent changes in the rates of prescribing of these psychiatric drugs. A better indication of this is trends in terms of standard dosage units (see note 2 for an explanation of this measure) (Figure 2): Figure 2 Psychiatric drug prescribing 1990-2000 in standard dosage units in selected regions These data show that the rising trend in prescription of psychiatric medication from 1990 to 2000 is less marked when measured in standard dosage units. In the more developed regions, the United States shows a growth of 70.1%, Europe shows a growth of 26.9%, Japan shows a growth of 30.9%. In the less developed regions, South America remains remarkably constant with a growth of only 1.6%, South Africa shows a growth of 13.1%, but the use of prescription drugs in Pakistan grows by 33.4% (although from a low base).7 This variation in the quantity of drug prescribes is instructive, but we see a rather different pattern when we relate the number of standard doses prescribed in each region (IMS figures) to its population (our data) (Figure 3). Figure 3 Psychiatric drug prescribing 2000 in standard dosage units per 100,000 population selected regions

But many specifically pharmaceutical issues have played a key role. In the United States. Japan and the United States? And how can the variations in the prescribing of different classes of drugs be explained? In Europe and the United States. The consequence has been a fundamental shift in the distinctions and relations between mental and psychological health and illness. for instance.000) and 1980 (when this figure had almost halved to around 70. Thus. in the UK. although it stands at around 12% of that in the more developed regions.5 Biotechnology between Commerce and Civil Society These figures for the year 2000 show that the annual rates of prescribing psychiatric drugs are actually remarkably similar in the more developed regions . the beliefs of the medical and psychiatric professionals and the demands of the patients and lay public have all played their part. However. or around 750 thousand standard doses per 100. perhaps even conceptions of personhood itself.000 persons.000) the major growth in the psychiatric drug market was in the use of tranquillizers (both major and minor) – from around 6 million prescriptions per year to around 24 million (Figure 4). with correlatively low levels of antidepressant prescriptions. South America and Pakistan. it is worth pausing to examine the prescribing data in more detail.000 persons. the licensing regimes in force in different regions. The marketing strategies of the companies. the availability of over-the-counter medication which does not show in this prescribing data.the United States. the rate of prescribing in the three less developed regions is roughly similar. the context has been the fundamental transformation of the locus of psychiatric care from the closed world of the asylum to an open psychiatric system. antidepressants form a much higher proportion of psychiatric drugs than any other region. within these figures. between 1960 (when the average number of inpatients in psychiatric hospitals was around 130. hypnotics and sedatives are proportionally low. . The USA is the only region where psychostimulants such as methylphenidate and amphetamine are a significant proportion of the psychiatric drug market. and antipsychotics. What accounts for the high rates of prescribing psychiatric drugs in the 'more developed' regions of Europe. High proportions of tranquillizer prescribing are shown in Japan.at an average of around 6. the relative costs of the drugs and the funding regimes in place.5 million standard doses per 100. Similarly. Europe and Japan . The United Kingdom Before considering these issues. there are significant regional variations in the proportions of different classes of psychiatric drugs being prescribed. amounting to almost 10% in 2000.

rose from about 34.358.5m prescription items to about 16. This is a point that should be born in mind throughout the paper: the increasing worldwide dependence of health services on commercial pharmaceuticals is not restricted to psychiatric drugs and much of the growth in this sector is in line with that in drugs used for other conditions.280.790 standard units in 1980 to 29.disguises the increase in the quantity of the drugs being prescribed which has risen almost five-fold. in view of the contemporary debates about the rise of the use of these drugs for the treatment of Attention Deficit Hyperactivity Disorder. antipsychotics (a re-classification of drugs previously classified as ‘major tranquillizers’ linked to beliefs about their specificity of action) and antidepressants and stimulants.2000 Number of Prescription Items Dispensed (thousands) (Source: Government Statistical Service) A decline in prescriptions for hypnotics and anxiolytics of about 32% (from about 24. The total cost of all these classes of psychiatric drugs rose tenfold in the period from 1980 to 2000.340 in the year 2000.5m prescription items per year) was matched by a rise in prescriptions for antidepressants of about 200% (from about 7. But the overall rise in prescription items dispensed .358.a growth of almost 30% (Figure 5). the total number of prescription items dispensed in the four main classes of drug used for psychiatric conditions .hypnotics and anxiolytics. However this is broadly consistent with the rising cost of the drug bill generally: expenditure on psychiatric drugs remains at about 8% of NHS drug expenditure. from around £50m per annum to around £530m in 2000. Figure 5 Psychiatric drug prescribing (England) 1980 .of about 130% .970 in 1980 to a staggering £29. from 6.Becoming Neurochemical Selves 6 Figure 4 Prescriptions for psychoactive drugs (millions) in the United Kingdom 1960-1985 (Source: Ghodse and Khan 1988) Over the following twenty years.5 million items to about 44.from just over 111 thousand items in 1980 to just over 260 thousand in 2000 . . The net ingredient cost of these ADHD related drugs rose from £72.340 in 2000: almost two thirds of this growth is accounted for by Ritalin which was first introduced to the UK in 1991.5 million .8 I will return to the increase in the use of antidepressants later.5m prescription items to around 22m prescription items per year). The small increase in the number of prescriptions dispensed for dexamphetamine and methylphenidate might seem surprising.

although both doctors and lay people often confused them with chlorpromazine and reserpine. arguing that the available studies failed to show that meprobromate was more effective than placebo in treating anxiety. This pattern that is largely explained by the rise and fall of the use of minor tranquillizers (Smith. By the end of the 1950s.is difficult to obtain. Smith. was the first of the benzodiazepines to come to market. in fact. annual US expenditure on such drugs totalled $850 million. it was not less toxic than Phenobarbital. by Community Mental Health Centers. each claiming to be better than the others. It has been estimated that by the mid 1970s more than one fifth of the non-institutionalized population received at least one prescription of psychotropic drugs annually. 1991) The first of the minor tranquillizers. and by 1980 the numbers more or less returned to their1964 levels. and referred to them all as 'tranquillizers'. 1991). mebrobromate. 1985: 150). Demand soon became greater than for any other drug marketed in the USA and around 35 other 'tranquillizers' were brought to market. marketed by Wallace under the name of Miltown. Figures on prescriptions dispensed by drugstores or pharmacies show that the total numbers of prescriptions dispensed in this way actually peaked in the early 1970s. Figure 6: USA: Psychiatric drug prescriptions filled in US drugstores 1964-1980 (Source: M. this first generation of minor tranquillizers were themselves soon to be displaced. and to outpatients in drugstores . and it soon became the most prescribed drug in the USA. However it soon turned out that it had some undesirable side effects and could cause fits if suddenly discontinued. In any event. These drugs displaced the barbiturates and other sedatives from their place in the pharmacopoeia. displaced Librium from its top spot in . also marketed by Roche. some claimed that. amid a welter of favourable publicity about 'happy pills' and 'aspirin for the soul' (my account is derived from Smith. Valium. that in 1977. and that in 1974 there were 70 million prescriptions for Valium (diazepam) and Librium (chlordiazepoxide) amounting to 3 billion tablets of Valium and 1 billion tablets of Librium (Brown. and by Wyeth as Equanil came onto the American market in 1955.7 Biotechnology between Commerce and Civil Society The United States Data on overall trends in psychiatric drug prescribing in the United States in the period from 1955 to 1980 . Librium.which would include drugs dispensed in hospitals. developed and marketed by Roche. 1991). a number of critical reviews were published.

They were instructed to remove the implications that the drugs should be used for managing the worries and stresses of everyday life. and again in the 1970s. show that while prescriptions for antidepressants rise until 1974 and then stay roughly constant. one woman in five and one man in thirteen was using 'minor tranquillizers and sedatives. Following this legislation. even though they do not reflect hospital prescribing. public eagerness and glowing reports about efficacy gave way to critical reviews calling for caution and further study. In 1962. initial professional enthusiasm. What of other psychiatric drugs over this period? Data on prescriptions filled at pharmacies. 1991). considered various aspects of these tranquillizers and other drugs. unlike the mild Miltown. promotional literature and advertisements. the FDA moved the benzodiazapines and meprobromate to its 'schedule IV' which controlled 'refills' or repeat prescriptions. the FDA required the manufacturers of minor tranquillizers to modify their advertising. psychiatry became increasingly a specialty oriented to the provision of medication. labelling and product information.2 percent) With the benzodiazapines as the entering wedge. prescribing practices. in fact. examining costs. Nonetheless. met theses alarms by arguing that the drugs could. in what was to become a familiar pattern. supported by many respectable physicians. especially when prescribed at high doses over long periods. And before long. In 1975. and also imposed reporting requirements on pharmacists: predictably. their were reports of 'overuse' and cries of alarm from some doctors and the press. The explanation for this pattern for antipsychotics may lie in the timescale of the acceptance that these drugs. an Act strengthened the powers of the Food and Drug Administration in evaluating the safety of drugs and regulating the ways in which they were advertised and promoted. on several occasions. 1997: 319):9 By 1970. those for anti-psychotics peak at the same date and then fall slowly. By the mid-1970s. But. produced adverse effects .Becoming Neurochemical Selves 8 1969 (Shorter. In the early years of the use of neuroleptic . psychiatrists were able to offer their patients a potent drug.3 percent to 50.notably the irreversible condition that became known as tardive dyskinesia. a series of Congressional hearings from 1959 to 1965. in response to publicly expressed concerns. and to stress the potential dangers of dependence and addiction and the difficulties consequent upon discontinuation. 1991: 12). be used appropriately – the problem could be solved by issuing clear guidelines for prescribing. that did not sedate them… The share of psychiatric patients receiving prescriptions increased from a quarter of all office visits in 1975 to fully one-half by 1990 (from 25. the term Valium was being used generically to mean tranquillizer (Smith. prescribing declined (Smith. The manufacturers.' meaning mainly the benzos… For the first time.

9 Biotechnology between Commerce and Civil Society drugs. medical negligence.20 percent .10 The definitive English language article on neurological complications of the antipsychotics was published in 1961. lips and tongue which now known as tardive dyskinesia was actually first described within a few years of the introduction of the neuroleptics (Leonard. 1961). Other lawsuits followed. 2002). the formal professional recognition of the condition and its causation opened the door for legal action. 1973). psychiatrists tended to assume that so-called extra-pyramidal effects in patients being administered neuroleptic medication .Parkinson like symptoms .). focussing on informed consent. 1956. in any event. The syndrome of late onset severe movement abnormalities most noticeable in the mouth. the view that long-term treatment might cause a problem was being given authoritative support (Ayd. 1999. if possible "neuroleptics should be discontinued at the first sign of tardive dyskinesia. Despite this cautious. 1967. According to David Healy. The FDA and the American College of Neuropsychopharmacology set up a Task Force which reported in 1973: it acknowledged that tardive dyskinesia could be presumed to result from treatment with antipsychotic drugs. the first case was in 1974.were signs that the drugs were working. vague and generally optimistic tone. Whilst the unnecessary use of high doses in chronic cases should be minimized" the medications could still “be used with confidence – the overwhelming clinical and objective evidence indicates that a majority of schizophrenic patients” should continue to receive medication (Task Force. although there were reports from the mid 1950s that Parkinson like symptoms and other effects might persist . Crane. when SmithKline & French settled a claim for Thorazine induced tardive dyskinesia and it seems that this led to the willingness of the manufacturer to acknowledge the risk of tardive dyskinesia in package inserts (Lennard and Bernstein. Over the 1960s many leading psychiatrists involved in the developments of psychopharmacology suggested that the dyskinesias could be demonstrated in untreated patients and were actually a sign of the illness or that. violation of civil rights and product liability. Whilst the condition was "an undesirable but occasionally unavoidable price to be paid for the benefits of prolonged neuroleptic therapy" . problems without the drugs were worse than those caused by the drugs. cited in Gelman. Most believed that these effects disappeared when the medication was discontinued.1974). and hence markers of a therapeutic reaction (This account is derived from Gelman. 1968.in the so-called 'neurotoxic reactions' (Hall. and Healy. But by the late 1960s. but there was continuing scepticism from many psychiatrists about the reality of this problem and its relation to drugs (Ayd. at least 10 . misdiagnosis. 1992: 129). 1999: 31). The American Psychiatric Association set up a task force chaired by Ross Baldessarini which reported in 1980: it acknowledged in its official summary that in routine neuroleptic drug use over six months to two years.

and a headline in the January 1984 issue of Clinical Psychiatry News warned its readers to 'EXPECT A FLOOD OF TARDIVE DYSKINESIA MALPRACTICE SUITS’ (Breggin 1993: 97. did not cause tardive dyskinesia.000 and $1 million. the search began for alternative drugs that would not produce such damaging side effects. A dual strategy took shape. seemed not to be ‘addictive’ and. and stated that they were “concerned about the apparent increase of litigation over tardive dyskinesia” (Breggin. January 1984). and the shadow of the law would once more fall over . By the end of the decade.000 and jury awards were averaging $1 million. were safe in overdose. This track would eventually lead to the marketing of the so-called 'atypical neuroleptics'. out-of-court settlements were averaging $300. would get more than minimal signs of tardive dyskinesia. But it also underpinned other attempts to engineer so-called 'smart drugs' which could be said to directly target the neurochemical bases of the illness. The gradual acceptance of the reality of tardive dyskinesia. These were apparently 'smart' targeted drugs that seemed to have minimal adverse effects. According to Peter Breggin. the official APA newspaper Psychiatric News carried the headline 'TARDIVE DYSKINESIA COURT CASES UNDERSCORE IMPORTANCE OF APA REPORT' and reported that two precedentsetting cases had been settled for $76. 1993: 97). the pharmaceutical industry met with FDA to discuss how to label the propensity of their compounds to cause tardive dyskinesia. of its prevalence. on 7th October 1983. so it seemed.Becoming Neurochemical Selves 10 of patients would get more than minimum tardive dyskinesia. triflueroperazine (Stelazine) came to an end (Healy. psychiatrists and the pharmaceutical companies were increasingly involved in litigation. according to The Psychiatric Times. On the other hand. and of its causation by drug treatment could not reverse the policy or the use of the drugs. tardive dyskinesia lawsuits were on the increase. 7 October 1983 and Clinical Psychiatry News. or at least the symptoms. The first ‘golden age’ of psychopharmaceuticals which had begun with Thorazine (Largactil in Europe) and which saw the development of a host of other antipsychotics: thioridazine (Melleril). confirmed that children were also at risk. he is citing Psychiatric News. But it would not be long after the introduction of Prozac and its sisters that these assumptions would be challenged. The first fruit of this line of thinking would be Prozac. with the minimum of collateral damage. antipsychotic drugs had become central to the rationale of deinstitutionalization in the United States by the midsixties and to the management of the decarcerated – or never incarcerated – population. In 1985 the American Psychiatric Association wrote to each of its members to repeat its warning that “at least 10-20% of patients in mental hospitals” and at least 40 percent of longer term patients. soon followed by closely related Selective Serotonin Reuptake Inhibitors. haloperidol (Haldol). On the one hand. But despite the law suits. 2002). By the 1980s. and.

These HMOs are commercial companies whose profits depend upon their success in implementing a . and there is great pressure to reduce Medicaid budgets (Elixhauser et al. And in the regime of 'managed care'. pressure on funding in the health care system. not just to determine new product development.11 Biotechnology between Commerce and Civil Society psychopharmacology. While the case was in fact settled out of court in 1987. 1997). Medicaid patients account for 50% of all hospitalisations for schizophrenia and 28% of all hospitalisations for depression. the dependence of psychiatry on psychopharmacology was entrenched over the 1980s. Since 1980. Non-profit organizations contributed 4 percent to health R&D funding and state and local governments added 7 percent (National Center for Health Statistics.S. It was used to argue that the most valid and convincing evidence of efficacy must be derived from randomised control trials. health R&D funding grew from 13 percent in 1980 to 52 percent in 1995. it generated much discussion. 2000). When pharmaceutical companies provide a majority of funding for research and development in the US health sector. The first of these relates to research and development. and that psychotherapies had not passed any equivalent of the scrutiny maintained by the FDA over drugs. Despite the problems of adverse effects that affected both the minor tranquillizers and the anti-psychotics. other legal decisions reinforced the overall push towards psychopharmacology as the treatment of choice for most psychiatric conditions. despite substantial increases in financial support for health research through the National Institutes of Health. psychiatrists and psychiatric institutions had to think of the legal consequences whenever they chose not to prescribe medication for their patients. Secondly. has led to a decline in overall rates of hospitalisation for all conditions by over 30% (Popovic and Hall. Indeed. the federal government's share of total health R&D funding dropped from 57% to 37%. and thus did not set a legal precedent. they clearly have considerable power. The pharmaceutical industry's potion of total U. the funders and the providers. During this same period. the funding of health care provision has shifted with the introduction of managed care and the reduction of in-patient treatment. amongst other things. but also to shape the very styles of thought which organise responses to mental health and mental illness. The famous Osheroff case brought in 1982 involved a claim of malpractice against Chestnut Lodge whose psychodynamic approach was made famous by Hannah Green in I Never Promised You a Rose Garden on the grounds that he was denied available psychiatric medication that had proven efficacy. Other changes in the US health care system in the 1980s also contributed to the rise of psychopharmacology. Although only 12% of the US population is covered by Medicaid. 1999). a Health Management Organisation acts as an intermediary between the users of health care services. 2002: Table 125). From this point on.

Indeed the growth in use of antidepressants may have contributed to the .703. Of course. peaking and falling away after 1998. which may be provided for particular conditions. such figures are affected by variations in price.0%). it does not reflect an increase in numbers of these drugs prescribed.203. sales of psychiatric drugs. Thus. at ex-manufacturer prices.3% was for tranquillizers (1990: 39. for example the lapse of patents on certain drugs and their availability in generic forms.1%): the increase in value here presumably arises from the marketing of the so-called atypical antipsychotics since.2%) and 3.9% was for psychostimulants (1990: 3. 22.502. as we see below. amounting to 205% overall. drug treatment outside hospital becomes the treatment of choice. and hence to increase the likelihood of compliance with medication.5%).Becoming Neurochemical Selves 12 range of what are euphemistically termed 'cost-containment techniques' procedural rules governing the choices of doctors and others.000 US dollars (1990: 2. In this context.486. and the type of service. Antidepressants show a steady growth over the period. refusing to authorise requests by medical staff for extended stay.000). totalled 15. Figure 8: USA: Psychiatric drug prescribing 1990-2000 in Standard Units (Source: IMS Health) Over the decade from 1990-2000 there were two principal contributors to the overall growth in prescribing. Tranquillizers show a 32. controlling the drug budget by monitoring prescribing practices in the interests of cost saving and insisting on generic alternatives where available. 9. 5. delimiting the amount of service. 58. behavioural or cognitive therapy may also be funded. perhaps.5% was for hypnotics and sedatives (1990: 9.11 A more accurate guide to trends is provided by data expressed in terms of the number of standard doses sold (Figure 8). focussed. designed to ensure that the patient has the in sight to recognise that he or she is suffering from an illness.2%). requiring physicians to adopts a step-care technique in which they begin with the lowest cost treatment and only progress to higher -cost alternatives if these are deemed 'ineffective'.5% growth over the decade. although short-term.8% was for antipsychotics (1990: 10. the current levels of psychiatric drug prescribing in the United States should come as no surprise (Figure 7). for example by placing strict limits on periods of hospitalisation.4% was for antidepressants (1990: 38. Figure 7: USA: Psychiatric drug sales 1990-2000 in US Dollars (Source: IMS Health) In the year from July 1999 to June 2000.

It seems that. because it appears that Prozac and the other SSRI drugs were now being prescribed for the treatment of conditions where minor tranquillizers would previously have been given. as that which is potentially treatable by antidepressants. But the traditional antidepressants also show a steady rise. dexamphetamine. amounting to around 45% of all drug prescribing. The aggregated data for prescriptions of psychostimulants from 1990 to 2000 (in Figure 8) thus initially seem surprisingly. which combines the trends in prescribing in the different drugs within each class.the CNS stimulants used in the treatment of ADHD. these antidepressants have spread beyond their initial niche. Two other groups of drug classed as psychostimulants were prescribed heavily in the United States up until the mid-1990s. to the availability of the new antidepressants. This illustrates some of the cautions that need to be used in interpreting this aggregated data. with tranquillizers constituting around 27%. However. the figures do not entirely bear that out (Figure 9). and extended their claims of efficacy to a whole class of relatively new conditions – the anxiety disorders. Although.13 Biotechnology between Commerce and Civil Society fall off in the use of tranquillizers in the mid-1990s. It is widely accepted that there is something of an epidemic of Attention deficit Hyperactivity Disorder in the United States. Glypolix. methamphetamine. The first of these were the amphetamine based drugs that were marketed heavily as anti-obesity drugs up to the mid 1990s. and by 2001 they still amount to 48% of the total antidepressant market. Figure 9 Antidepressant prescribing in the USA 1990-2001 In SUs The SSRI family of antidepressants do show a spectacular rise of over 1300% over this period – with final prescribing levels more or less equally split between fluoxetine (Prozac). whilst the commonly accepted view is that the growth in the diagnosis of depression is linked. Dipondal. including dexfenfluramine (Adifax. Diomeride. At the end of the decade. what is involved here is the increase in the diagnosis of something called depression. as we shall see below. not just amphetamines. antidepressants were by far the most extensively prescribed psychiatric drug. Sertraline (Zoloft) and Paroxetine (Paxil) though with the newer SNRIs coming up fast. But it covers a range of different preparations. though from a higher base. and methylphenidate . . remaining at just under 10% of all prescribed psychiatric drugs. however it is treated. more or less directly. The class of psychostimulants as a whole has shown very little overall growth over this decade.

data provided to the US Drug Enforcement Agency by IMS Health show that after increases in the early 1990s. Data in the Narcotics Control Board reports for 1995. Our own IMS data shows that the total number of standard units prescribed rose by almost 800 percent from 1990 to 2000. These were removed from the US market around 1997 after evidence of severe adverse effects was finally accepted (Muncie. calculated in kilograms per year. had risen by 500% from 1991 to 1999. from about 1. and those for amphetamines. Isomerin. and those for amphetamine had risen even more sharply. Figure 11 Calculated Daily Consumption of Methylphenidate per 1000 inhabitants in Selected Regions . by 2000%. The medications used here are potential drugs of abuse subject to the provisions of Article 16 of the 1971 Convention on Psychotropic Substances. Siran) and fenfluramine.Becoming Neurochemical Selves 14 Isomeride. Obesine. Figure 10 Psychostimulant prescribing in the USA 1990-2001 In SUs The epidemic of prescribing for ADHD in the United States seems a pretty clear example of a ‘culture bound syndrome’.S. prescriptions for methylphenidate levelled off at about 11 million per year. The U. Collectively this indicates an increase of prescriptions for ADHD by a factor of 5 in the period 1991 to 1998. to claim that domestic sales of methylphenidate. 2001).800 million. which reports annually. Drug Enforcement Administration used UN Narcotics Control Board figures in its congressional testimony in May 2000. primarily Adderall (which is an amphetamine-dextroamphetamine mixed salt) increased dramatically since 1996. If we consider just the drugs used to treat ADHD. as their status changed and they became available over-the-counter. from around 225 million to around 1. 1996 and 1998 (Figures 11 and 12) show the trends for the consumption of methylphenidate and amphetamines in various countries from 1993 to 1998. the early growth being in Methylphenidate – Ritalin – whose dominance has recently been challenged by dexamphetamine – Adderall. such as Viviran.3 million per year to about 6 million per year. Drug Enforcement Agency. The second group of drugs were stimulants based on caffeine and epinephrine. 2000). which also disappear from the IMS data in the mid-1990s. although from a lower base (U. and their manufacture and consumption is monitored by the United Nations Narcotics Control Board. S. Redux.

Figure 13 Psychiatric Drug Prescribing in Selected Regions Proportions prescribed 2000 in different therapeutic classes in SU per 100. Indeed fluoxetine hydrochloride was never marketed in Japan. then. a far greater proportion of those prescriptions are for tranquillizers and anti-psychotics and less than 15% are for antidepressants. although at a much lower level. at least in the United States and the UK. at around 6. 1998. South America and Pakistan. while the overall rate of psychiatric drug prescribing in Japan is broadly similar to that in Europe and the United States.6 million SUs per annum per 100. How. between the three ‘less developed’ regions of South Africa. and in Europe more generally.000 population. 1998. Accounting for psychopharmacology The patterns of growth in the commercial value of the market for psychopharmaceuticals are clear enough. As we have seen earlier. can we account for the specificity of the UK and USA? The best researched case is that of depression. the simplest . 2000 Overall. there are broad similarities between overall rates of psychiatric drug prescribing proportional to population size in the USA. Japan seems not to have had the wave of concerns over the benzodiazepines and the traditional neuroleptics that shook psychopharmacology in the West nor does it seem to have experienced the ‘epidemic’ of depression and antidepressants (Healy 2002).000 population (Source: IMS Health) The most interesting comparator for the UK and the USA is Japan. Of course.000 population – or an average of around 70 doses per person per year. 2000 Figure 12 Calculated Daily Consumption of Amphetamine per 1000 inhabitants in Selected Regions (Source: UN Narcotics Control Board 1997. and the first SSRI type drugs (fluvoxamine and paroxetine) did not come on the market until 1999 and 2000. and broad similarities.15 Biotechnology between Commerce and Civil Society (Source: UN Narcotics Control Board 1997. these data show that by the year 2000. And ADHD is only just being ‘discovered’ in Japan. As we saw earlier. Europe and Japan. around seven million standard doses of psychiatric medication were being prescribed in the United States per 100.

But far more important is the effect untreated mental illness has on the lives of individuals and their loved ones. if current trends for demographic and epidemiological transition continue. most people with serious mental illness need medication to help control symptoms. for example. These illnesses have a great impact on society. and ability to relate to others. that that depression is more common than has previously been realised. argued that it is exacerbated by social factors such as an aging population. or poor upbringing. not just of the drug companies and some psychiatrists.7% of the total burden of disease. Just as diabetes is a disorder of the pancreas. and second that we now have powerful and effective new drug therapies to treat it. The first seems to be the view. The second is certainly the view. Mental illnesses do not discriminate. self-help groups. Supportive counseling. unemployment and similar stressors. In the United States. but also of some key campaigning groups. bipolar disorder. of the World Health Organisation. depression will then be the highest ranking cause of burden of disease” (WHO 2001: 30). gender. or socioeconomic status. lack of character. and predicted “By the year 2020. moods. housing. Four of the top ten leading causes of disability are mental illnesses including major depression. schizophrenia and obsessive compulsive disorder. Thus by 2001 the National Alliance for the Mentally Ill proclaims mental illness a treatable brain disorder treated with medication just like diabetes is treated with insulin:12 Mental illnesses are disorders of the brain that disrupt a person's thinking. the burden of depression will increase to 5. In the developed regions. takes insulin. they affect people of every age. feeling. mental illnesses are disorders of the brain that often result in a diminished capacity for coping with the ordinary demands of life. becoming the second leading cause of DALYs [disability adjusted life years] lost. Mental illnesses are not the result of personal weakness. Worldwide it will be second only to ischemic heart disease for DALYs lost for both sexes. vocational rehabilitation. race. religion. and the estimated cost of mental health care is over $150 billion per year. These brain disorders are treatable. over seven million adults and over five million children and adolescents suffer from a serious. first. As a person with diabetes. poverty. And it says of depression:13 . whose 2001 report claimed depression affects over 340 million people worldwide. contributing to recovery. income assistance and other community services can also provide support and stability.Becoming Neurochemical Selves 16 explanation for the remarkable rise in diagnosis of depression and the prescription of antidepressants over the last decade is. chronic brain disorder.

Not everyone with a genetic predisposition develops depression. There is an increased risk for developing depression when there is a family history of the illness. poverty. Older sociological explanations that linked the rise of mental disorders to general features of social organization have fallen out of fashion – for example. then clinical states of depression result. This view of the biochemical basis of. the suggestion that urban life generates neurasthenia or that capitalism isolates individuals and hence places strains on them that lead to mental breakdown – with the possible exception of feminist accounts in terms of patriarchy. scientific research has firmly established that major depression is a biological brain disorder. But these factors do not seem sufficient to account for such a rapid increase in diagnosis and prescription. Some illnesses and some medications may also trigger depressive episodes. but some people probably have a biological make-up that leaves them particularly vulnerable to developing depression. Darkness Visible by William Styron. a major loss or change. Scientists have also found evidence of a genetic predisposition to major depression. such as the death of a loved one. Scientists believe that if there is a chemical imbalance in these neurotransmitters. Solomon. depression has also been popularised in a number of autobiographical accounts by wellknown public figures: for example. campaigns to ‘recognise depression’ operate in these terms: arguing that depression is an illness. Life events. It is also important to note that many depressive episodes occur spontaneously and are not triggered by a life crisis. In both the UK and the USA. that it is often untreated. 1991. or other risks. often inherited in the form of increased susceptibility and triggered by life events. even if it was accepted that contemporary social conditions were more pathogenic than those that preceded them. serotonin. physical illness. and that drugs form the first line of treatment – for example in the recent Defeat Depression in the UK. Antidepressant medications work by increasing the availability of neurotransmitters or by changing the sensitivity of the receptors for these chemical messengers. unemployment or precarious and stressful working conditions are associated with increased levels of psychiatric morbidity. chronic stress. may trigger episodes of depression.17 Biotechnology between Commerce and Civil Society Whatever the specific causes of depression. and treatability of. Alain Ehrenberg has recently suggested that the very shape of depression is the reciprocal . 2001 ). and alcohol and drug abuse. Most of those who have explored this rise are not satisfied with such a ‘realist’ account. or The Noonday Demon by Andrew Solomon (Styron. Norepinephrine. and dopamine are three neurotransmitters (chemical messengers that transmit electrical signals between brain cells) thought to be involved with major depression. There is certainly convincing epidemiological evidence that such factors as poor housing.

choice and active self-fulfilment. it is certainly the case that the shape and incidence of the pathology of depression in western developed nations can only be understood in relation to contemporary conceptions of the self involving the obligation of freedom: responsibility. in this sense.they are now mapped upon the body itself. By somatic individuality. The sense of ourselves as ‘psychological’ individuals that developed across the twentieth century – beings inhabited by a deep internal space shaped by biography and experience. 2000). it involves understanding troubles and desires in terms of the interior ‘organic’ functioning of the body. At the start of the twentieth century. First. to choice. the source of our individuality and the locus of our discontents – is being supplemented or displaced by what I have termed ‘somatic individuality’ (Novas and Rose. no doubt. At the other end. But other factors also need to be addressed. or one particular organ of the body – the brain. and the tendency for contemporary understandings of health and illness to be posed largely in terms of treatable bodily malfunctions. the readiness of those who live in such cultures to define their problems and their solutions in terms of health and illness. to self-realisation and self improvement act as a norm in relation to which individuals govern themselves and are governed by others. and against which differences are judged as pathologies. exercise. is to code one’s hopes and fears in terms of this biomedical body. and hence the exemplary experience of pathology what that of neurosis. through diet.Becoming Neurochemical Selves 18 of the new conceptions of individuality that have emerged in modern societies (Ehrenberg 2000). psychological trauma . At one end of the spectrum this involved reshaping the visible body. that is to say to think of oneself as ‘embodied’. and tattooing. an inability to perform the tasks required for work or relations with others. The continual incitements to action. they are undoubtedly linked to a more profound transformation in personhood. and seeking to reshape that – usually by pharmacological interventions. and to try to reform. he argues. cure or improve oneself by acting on that body. Second. the norm of individuality was founded on guilt. these developments are related to the increasing salience of health to the aspirations and ethics of the wealthy west. Whilst such a global cultural account is unconvincing. This is not the place to explore the processes that have led to such . the reciprocal of that norm of active self-fulfilment is depression. now largely defined as a pathology involving the lack of energy. I mean the tendency to define key aspects of ones individuality in bodily terms. and to understand that body in the language of contemporary biomedicine. repression. Whilst discontents might previously have been mapped onto a psychological space – the space of neurosis. To be a ‘somatic’ individual. But in societies that celebrates individual responsibility and personal initiative.

From this point on it appeared that there was an untapped market for antidepressant drugs outside hospitals. Across the 1960s depression became linked to levels of secretion and reuptake of brain amines in the synapses – gradually coming to focus on serotonin. The serotonin hypothesis of depression was formulated. panic disorder. it sold a new idea of what depression was and how it could be diagnosed and treated. of some support and anti-stigma groups.. of health care professionals. Ayd’s book of 1961. here. There was also an audience for the idea that the certain drugs specifically targeted the neurochemical basis of depression.14 This involves a co-production of the disease. but that it did not require a psychiatrist for its diagnosis – it “could be diagnosed on general medical wards and in primary care offices” (Healy 1997: 76). responsible.000 copies of Frank Ayd’s book (Ayd. The earliest (and most quoted) example of this co-production of disorder and treatment concerns depression. obsessive compulsive disorder and post traumatic stress disorder. perhaps more significant than any individual drug. and pharmaceutical companies invested funds in research to develop antidepressants. Most notable. Rating scales to identify depression were developed (notably the Hamilton depression scale). the diagnosis and the treatment. it . choosing self have come to be seen as depression. which concerns the reshaping of particular kinds of experiences as mental disorders amenable to pharmacological treatment. and despite its obvious scientific inadequacies.19 Biotechnology between Commerce and Civil Society discontents and their treatments being understood in this way – premised on the belief that the brain itself is the crucial locus of the disorder and the target of the treatment. However it is possible to consider one limited aspect of this. but also changed the shape of the disorder itself. First. it became the basis of drug development leading to the SSRIs and the basis of a new way of thinking about variations in mood in terms of levels of brain chemicals that penetrated deeply into the imagination of medical practitioners and into popular accounts of depression. This presupposition was actually three sided. The central presupposition. is the way in which many pathologies of the active. Merck bought up 50. Recognizing the Depressed Patient argued that much depression was unrecognized. but most significantly of the pharmaceutical companies themselves. Merck not only sold amitryptiline. it was premised on the neuroscientific belief that these drugs could. social anxiety disorder. Frank Ayd had undertaken one of the key clinical trials for Merck. As Healy argues. and ideally should have a specificity of target. This can be seen in the strategies of psychiatrists. was that of specificity. and depression itself has come to be linked with anxiety disorders – in particular generalized anxiety disorder. 1961) and distributed it worldwide. these generated new norms of depression which were not only used to test the efficacy of drugs. Second. which filed the first patent for the use of amitryptiline as an antidepressant.

On the other that assemblage of virtues is condensed into a simple brand name – Lustralmanufactured by Pfizer (marketed as Zoloft in the USA) with its smiley image and rising sun logo. These presuppositions have fuelled an industry of commentary – utopian or dystopian – on cosmetic psychopharmacology and the possibilities of reshaping our human nature at will. The three presupposition were then mapped onto one another. Or consider this advertisement for Prozac published in the American Journal of Psychiatry in 1995. compliance and simplicity. and that they could be ameliorated by drugs designed specifically to affect them. Take this advertisement for Lustral (sertraline) published in the British Journal of Psychiatry in 1991: Figure 14 Lustral: “The choice is simple – with bright prospects in mind” British Journal of Psychiatry. desire. 2002). low side-effects. desires. 2002. 1991 On the one hand. that anomalies in each type were related to specific psychiatric symptoms. in which a molecule was designed with a shape that would enable it specifically to lock into identified receptor sites in the serotonin system – hence affecting only the specific symptoms being targeted and having a low ‘side effect profile’. its status was confirmed by clinical reports and popular accounts such as those given by Peter Kramer to Elizabeth Wurtzel of the specific psychological transformations wrought by the drug. effectiveness. will.Becoming Neurochemical Selves 20 was premised on the clinical belief that doctors or patients could specifically diagnose each array of changes in mood. it was based on the neuroscientific belief that specific configurations in neurotransmitter systems underlay specific moods. than from the belief that it was first ‘smart drug’. And. the simple belief that there was one kind of receptor for each neurotransmitter was shown to be wrong – in the case of serotonin there were at least seven ‘families’ of 5HT receptors and most had several subtypes. Thus the iconic status of Prozac arose less from its greater efficacy in treating clinical depression. the specific advantages of the molecule in question. sertraline. affect as a discrete condition. on the other hand. It was now argued that each of these subtypes of receptors had a specific function. Third. but it did not. This might have proved fatal for this explanatory regime. Fukuyama. The premises of specificity were central to the vigorous campaigns that the pharmaceutical companies mounted to marker their products to physicians. low dependency. . and affect. as neurochemical and pharmacological research proceeded. are stressed – its selectivity. However. most recently from Gregory Stock on the and former side and Frances Fukuyama on the latter (Stock.

and the artificial raising of the levels by the drugs leads to a down regulation of the bodies own production of. For a belief in the reciprocal specificity of disorders and drug action implies that the drugs. known as Seroxat in Europe) for depression.which is Australia’s most widely used antidepressant . obsessive compulsive disorder and even low self-esteem. the first lawsuit against Prozac reached the courtroom in Louisville. if that were not enough. had shot 28 people at the printing plant where he worked. For some.16 Recall that Prozac was initially marketed as a specific for mild to moderate depression. acting. As the first generation of the drugs goes out of patent.4m (£4. sweating. killing 8 before shooting himself. This may have something to do with the fact that in Autumn 1994. in May 2001.caused David Hawkins to murder his wife and attempt to kill himself: “I am satisfied that but for the Zoloft he had taken he would not have strangled his wife” (Justice Barry O’Keefe). ordered GlaxoSmithKline to pay $6.7m) to the family of Donald Schell who shot his wife. 1995 “The Prozac promise” to the doctor and his or her patient is to deliver the “therapeutic triad” of convenience. confidence and compliance. nausea and much more – which occur when patients who have been taking these drugs for a while cease to take them – no doubt caused by the fact that the molecules act very widely in the body. on eating disorders. and the span and limits of their efficacy. court in Cheyenne. should determine the criteria for . but was soon surrounded by claims that it was much more versatile. this questioned the very distinctions and classifications on which modern American psychiatric medicine rests. But one can note here the increased space in he advertisement devoted to adverse events.two days after his GP prescribed Paxil (paroxetine. an Australian judge ruled that having been prescribed sertraline – Zoloft . for example. daughter and granddaughter and then killed himself . or sensitivity to the molecules in question. The jury decided that the drug was 80% responsible for the deaths. the manufacturers are also fighting against a shoal of analogous cases. And two weeks earlier. This case brought longstanding concerns about adverse effects of these drugs into the public domain – concerns about increases in agitation (akathesia) and suicidal ideation in a small but significant number of those administered Prozac which had led the German licensing authorities to insist upon product warning in 1984 before they would issue a licence. criticisms are now mounting of the difficulties of withdrawing from this medication – not dependency as is often suggested.21 Biotechnology between Commerce and Civil Society Figure 15 The Prozac Promise American Journal of Psychiatry. concerning Joseph Wesbecker who some five years earlier. Thus in June 2001. but the severe and unpleasant physical effects – pains. shortly after being prescribed Prozac.15 And.

Panic Disorder and Generalized Anxiety Disorder and their relation. the section on prevalence of this disorder (coded 300. because it allows marketing for the licensed indication. Whilst the USA is one of the few countries that allow ‘direct to consumer’ advertising of prescription drugs – which has grown into a $2.it was widely being claimed that GAD affected “more than 10 million Americans. GAD. the lifelong prevalence rate for Generalized Anxiety Disorder was approximately 3%. from depression. In anxiety disorder clinics. 1994). What was characteristic about this campaign is that it marketed. however. and hence the disorder could be freed.02) in the third. when GlaxoSmithKline announced that the US Food and Drug Administration (FDA) had approved Paxil for the treatment of GAD – the first SSRI approved for this disorder in the US . By April 2001. The clinical trials of Paxil in the treatment of GAD thus enabled it to be advertised as a specific treatment for this condition.Becoming Neurochemical Selves 22 inclusion in. By the publication of DSM IV. mental disorders. In this move. approximately 12% of the individuals present with Generalized Anxiety Disorder” (APA. Paxil. the disorder is not commonly diagnosed in clinical samples” (APA. The best example here concerns the anxiety disorders Social Anxiety Disorder. not so much the drug. and could be separated out from the general class of mood disorders. and the lifetime prevalence rate was 5%. revised edition of the Diagnostic and Statistical Manual of the American Psychiatric Association said “When other disorders that could account for the anxiety symptoms are ruled out [they previously stipulated that the disorder should not be diagnosed if the worry and anxiety occurs during a mood disorder or a psychotic disorder. Paxil had been widely used “off label” for the treatment of GAD before being specifically licensed for the condition. for example]. or by licensing their existing drugs as specifics for particular DSM IV diagnostic categories. GAD was reframed: the diagnosis could now co-exist with mood disorders. Hence. more immediately. Let me focus on Generalized Anxiety Disorder (GAD). either by making minor modifications to produce new molecules.5 billion a year industry since drug advertising legislation was relaxed in 1997 – it is not the only country where “disease mongering” has become a key marketing tactic. the same section read “In a community sample. 1987: 252). in 1994. 60 percent of whom are women”. as the disease. Companies seek to diversify their products and niche market them. As recently as 1987. in the first instance. and the boundaries around.17 In fact. in its public representations at least. as soon as the licence was issued n the Spring of 2001. And once it could stand as a diagnosis without subsumption into the class of depression. its prevalence could be recalculated. Licensing is significant. But. with one particular brand – Paxil owned by GlaxoSmithKline. GlaxoSmithKline engaged in a marketing campaign in the US. this diversity of classifications provides a key marketing opportunity.18 As Ray .

19 “Paxil ® … Your life is waiting” announces the Paxil website. and promoting maximal estimates of prevalence. directly or indirectly funded by the pharmaceutical company who have the patent for the treatment. Disease awareness campaigns. Figure 16 Paxil: “The real story about chronic anxiety” US Television. 2003). This involved the use of the public relations company to place stories in the press. They aim to draw the attention of lay persons and medical practitioners to the existence of the disease and the availability of treatment. October 2000 Here is how the action of Paxil is described to physicians in the information issued by the manufacturers:21 The antidepressant action of paroxetine …its efficacy in the treatment of social anxiety disorder … obsessive compulsive disorder [OCD]. point to the misery cause by the apparent symptoms of this undiagnosed or untreated condition. and interpret available data so as to maximise beliefs about prevalence.20 And consider the text of a “direct to consumer” television advertisement for Paxil in the United States in October 2001 (Figure 15). irritable bowel syndrome and Lotronex. and doctors eager to diagnose under-diagnosed problems (Moynihan. erectile dysfunction and Viagra. shaping their fears and anxieties into a clinical form.23 Biotechnology between Commerce and Civil Society Moynihan and others have recently pointed out. These are not covert tactics – as a quick glance at the Practical Guides published on the Web by the magazine Pharmaceutical Marketing will show. this process involves alliances are formed between drug companies anxious to market a product for a particular condition. Heath and Henry. Amongst the examples given by Moynihan et al. These often involve the use of public relations firms to place stories in the media. proclaiming Paxil to be the first and only FDA-approved SSRI for GAD – a site which helpfully provides a Self-Test for the condition with encouragement to consult a healthcare practitioner who can make the diagnosis. Moynihan. biosocial groups organised by and for those who suffer from a condition thought to be of that type. – which include baldness and Propecia. 2002. funding a large conference on social phobia. and panic disorder [PD]) is presumed to be linked to potentiation of serotonergic activity in the central nervous system resulting from inhibition of neuronal reuptake of . an alliance with a patients group called the Obsessive Compulsive and Anxiety Disorders Federation of Victoria. and Pfizer’s promotion of the new disease entity of ‘female sexual dysfunction’ – is the promotion by Roche of its antidepressant Auroxix (moclobemide) for the treatment of social phobia in Australia in 1997. providing victims who will tell their stories and supplying experts who will explain them in terms of the new disorder.

5-HT). Pfizer’s bought the rights to Pagoclone from Indevus Pharmaceuticals. 5-HT1-. alpha2-. In vitro radioligand binding studies indicate that paroxetine has little affinity for muscarinic. Disease. Pfizer with Zoloft – or to patent and licence new molecules specifically for this diagnosis. These links and relays between classification of disorders. licensed and marketed for the treatment of particular DSM IV diagnostic classifications. tested.Wyeth with Venlafaxine XF. antagonism of muscarinic. alpha1-. sedative and cardiovascular effects for other psychotropic drugs Thus these rather general and fuzzy new disorders such as OCD and PD are connected up to a whole style of molecular argumentation designed to emphasise the specificity of the neurochemical basis of the diagnosis and the mode of action of the drug. Paxil had arrived relatively late on the scene. and by 2001. beta-adrenergic-. promoted. but returned them in June 2002 when the results of its clinical trials failed to show levels of efficacy significantly above placebo – Indevus stocks dropped by 65% on the day of the announcement and Pfizer concentrated their efforts on their own drug Pregabalin. This new style of thought is thus simultaneously pharmacological and commercial. dopamine (D2)-. licensing and promoting psychopharmaceuticals have recently come in for much criticism. As an SSRI drug for the treatment of depression. But nonetheless the rate of increase in prescribing in the US kept pace with the brand leaders. histaminergic and alpha1-adrenergic receptors has been associated with various anticholinergic. 5HT2.22 Shareholder value and clinical value appear inextricably entangled.and histamine (H1)-receptors. Many leading figures in American – and worldwide – psychiatry act as consultants for the . drug and treatment thus each support one another though an account at the level of molecular neuroscience. as it succeeded in linking itself to the treatment of the anxiety disorders. marketing disorders and testing. Studies at clinically relevant doses in humans have demonstrated that paroxetine blocks the uptake of serotonin into human platelets.Becoming Neurochemical Selves 24 serotonin (5-hydroxy-tryptamine. Figure 17 SSRI and related drug prescribing USA 1990-2001 Source: IMS Health Other drug manufacturers rushed to trial and re-licence their own antidepressants so that they could promote them as treatments for GAD and the other related anxiety disorders. Drugs are developed. it achieved a market share about equal to Pfizer’s Zoloft and Lilley’s Prozac. In vitro studies in animals also suggest that paroxetine is a potent and highly selective inhibitor of neuronal serotonin reuptake and has only very weak effects on norepinephrine and dopamine neuronal reuptake.

and is currently the chairman of the first Gordon Research Conference on Psychogenetics. Pharmacogenomics Inc. and indeed have financial interests and shares in the companies themselves. and a growing proportion of psychiatrists find it difficult to think otherwise. A way of thinking has taken shape. advise the licensing authorities on the acceptability and risk of drugs. and Chief Executive Officer of Pharmacogenomics Inc. are involved in trialling. has published over three hundred articles on neuropsychopharmacogenetics and is a full professor of Pharmacology at the University of Texas Health Science Center.24 Blum. Conclusions By the 1990s a fundamental shift had occurred in psychiatric thought and practice. rely upon them for funds for their research. The newsletter of Secular Organizations for Sobriety – an organization providing a non-religious alternative to "Twelve Step" recovery programs – provides us with a helpful biography. In this way of thinking. San Antonio.23 Take Professor Kenneth Blum as an example chosen more or less at random. And no matter that most of the new smart drugs are no more effective than their dirty predecessors for moderate or severe depression – they are favoured because they are claimed to be safer. a member of the Advisor Board of this organization.25 Biotechnology between Commerce and Civil Society pharmaceutical companies. He chairs scientific conferences worldwide including two Gordon Alcohol Research Conferences (1978. and to have fewer ‘unwanted effects’. all explanations of . is considered an international authority in neuropsychopharmacology and genetics. are on the committees responsible for revising and updating diagnostic criteria. Scientific Advisor for Zig Ziglar Corporation. testing and evaluating their products. But he is also the managing director of 1899 Limited Liability Corporation a Virginia biotechnology firm. No matter that there was little firm evidence to link variations in neurotransmitter functioning to symptoms of depression or any other mental disorder in the living brains of unmedicated patients – although many researchers are seeking such evidence and occasional papers announce that it has been found. Blum is the author of numerous articles that claim to find associations between the genes responsible for various aspects of the neurotransmitter systems – such as dopamine D2 receptors and dopamine transporters – and particular DSM IV pathologies especially those related to substance dependency and various forms of ‘compulsive’ behaviour. 1982). is a wholly owned subsidiary of ACADIA Pharmaceuticals which specialises in genomicsbased drug discovery and tries to link genomic and chemical information to generate gene-specific small molecule drugs with improved side effect profiles for neuropsychiatric and related disorders. and is commercializing this pipeline through licensing and discovery collaborations with pharmaceutical partners.

neurotransmitters. Many of these large multinational conglomerates make a considerable proportion of their income from the marketing of psychiatric drugs. Paul Rabinow’s assessment of the new life sciences is especially apt for psychiatry – the quest for truth is no longer sufficient to mobilise the production of psychiatric knowledge – health – or rather. And. or indeed up until the middle of the twentieth. as we all know. become part of the psychopharmacological factory. the profit to be made from promising health . but unemployment. Of course. in the second half of the twentieth century. psychotherapy and counselling became big business. The factories of the pharmaceutical companies are the key laboratories for psychiatric innovation. Only the large pharmaceutics companies can now afford the risk capital involved in developing. but biography – family stress.has become the prime motive force in generating what counts for our knowledge of mental ill health (Rabinow. this means that these commercial decisions are actually shaping the patterns of psychiatric thought at a very fundamental level. psychiatry has become big business. the clinics. Nonetheless. in attracting market share is key to maintaining the shareholder value of the company. trialling and licensing of a new psychiatric drug. 1996). One of the eugenic arguments in Nazi Germany was that the care of the psychiatric ill was an enormous drain on the public purse (Burleigh. and their success. 1972).Becoming Neurochemical Selves 26 mental pathology must ‘pass through’ the brain and its neurochemistry – neurones. Not that biographical effects are ruled out. Environment plays its part. A few decades ago. receptors. the GPs surgeries and the private psychiatric consulting room . through their impact on this neurochemical brain. But psychiatry itself – in the mental hospitals. And the fabrication and action of psychiatric drugs is conceived in these terms. 1994).also became a huge and profitable market for the pharmaceutical industry. enzymes… Diagnosis is now thought to be most accurate when it can link symptoms to anomalies in one or more of these elements. ion channels. but from another perspective the developments in .has effects through its impact on this brain. and the psychiatric laboratory has. And experiences play their part – substance abuse or trauma for example .but once again. sexual abuse . they now seem ‘only common sense’. such claims would have seemed extraordinarily bold – for many medico-psychiatric researchers and practitioners. One of the criticisms of the private madhouses before the spread of public asylums was that they were generating what was termed ‘a trade in lunacy’ in which profit was to be made by incarceration – leading to all manner of corruption (Parry Jones. And because contemporary psychiatry is so much the outcome of developments in psychopharmacology. synapses. or failure. No-one made enormous sums out of public psychiatry in the nineteenth century. poverty and the like have their effects only through impacting upon this brain. in the same movement. membranes. in a very real sense.

lived and understood. as if illness.27 Biotechnology between Commerce and Civil Society psychiatric drug use are merely one dimension of a new set of relations between ideas of health and illness. Drugs such as Alazopram are rewriting the norms of social interaction. its kinship relations. but previous generations of pharmaceuticals for contraception. Premarin and other forms of hormone replacement treatment have rewritten the norms of female ageing. Xanax is 10th – it is a benzodiazapine used for the management of anxiety disorders . As for psychiatric drugs in the top twenty most prescribed drugs in the USA in 2001. Atenolol and Norvasc for the long term management of high blood pressure. in certain key respects. practices of treatment and prevention of bodily malfunctions.Zoloft (sertraline) and Paxil (paroxetine) – are in 14th and 15th place. economics and ethics of life itself. to identify this new medico-industrial complex and to point to its power is not to critique it. Prilosec for the treatment of Gastroesophageal Reflux Disease and heartburn. and commercially driven innovation.25 These are the drugs most amenable to the extension and reshaping of the boundaries of disease and ‘treatability’. They promise a power to reshape life pharmaceutically that extends way beyond what we previously understood as illness. Of course. But the consequences of many of the developments we have charted here cannot be reduced to a debate about efficacy.and two of the SSRIs we have discussed here . Not just Premarin and its sisters. Premarin for the treatment of the effects of the menopause in particular its effects on sexuality. In a situation where only investment of capital on a large scale is capable of producing new therapeutic agents. such linkages of health and profitability might well be the inescapable condition for the creation of effective drugs. for human capital is now to be understood in a rather literal sense – in terms of the new linkages between the politics. have rewritten the norms of reproduction – its timetables. This is not simply blurring the borders between normality and pathology. So the capitalisation of the power to treat intensifies the redefinition of that which is amenable to correction or modification. The best selling drugs these days are not those that treat acute illnesses. but those that are prescribed chronically. These include Lipitor for the lowering of blood lipid levels thought to predispose to heart attack and stroke. We are seeing an enhancement in our capacities to . we now must analyse bioeconomics and bioethics. or widening the net of pathology. marketing and competition for profits and shareholder value. whose coherence and very existence as illness or disorders are matters of dispute. the most widely prescribed of the new generation of psychiatric drugs treat conditions whose borders are fuzzy. We have seen that. and which are not so much intended to ‘cure’ a specific transformation from a normal to a pathological state as to modify the ways in which vicissitudes in the life of the recipient are experienced. Where Foucault analysed biopolitics. treatment and cure were independent of one another.

and the enhancement of capacities. interpret. A cascade of claims are made that everything from chocolate to exercise makes you feel good because it ‘enhances serotonin levels’. The significance of the emergence of treatments for mental ill health lies not only in their specific effects.Becoming Neurochemical Selves 28 adjust and readjust our somatic existence according to the exigencies of the life to which we aspire. Rather. in the sense identified by Foucault – they are societies of control. the theme of the centrality of sexuality to our psychic life. Hence the growing market for non-prescription products that claim to enhance serotonin levels in the brain – in health food shops and of course on the internet. These new self-technologies do not seek to return a pathological or problematic individual to a fixed norm of civilised conduct through a once-off programme of normalisation. Where discipline sought to fabricate individuals whose capacities and forms of conduct were indelibly and permanently inscribed into the soul – in home. but also in the way in which they reshape the ways in which both experts and lay people see. the body itself. As is well known. designed. It seems that individuals themselves are beginning to recode their moods and their ills in terms of the functioning of their brain chemicals. And these pharmaceuticals offer the promise of the calculated modification and augmentation of specific aspects of self-hood through acts of choice. and. But they are entangled with certain conceptions of what humans are or should be – that is to say. repression. adjustment. a constant work of modulation. the Oedipus complex. judgements internalised in very idea of these drugs. Gilles Deleuze (1995) has suggested that contemporary societies are no longer disciplinary. Psychiatric drugs today are conceived. neuroses. the active and responsible citizen must engage in a constant monitoring of health. speak about and understand their world. improvement in response to the changing requirements of the practices of his or her mode of everyday life. values. and to act continually on him or herself to minimise risks by reshaping diet. by means of pharmaceuticals. Psychoanalysis brought into existence a whole new way of understanding ourselves – in terms of the unconscious. The new neurochemical self is flexible and can be reconfigured in a way that blurs the boundaries between cure. psychiatrists and other mental health practitioners are beginning to see the problems their clients and patients . In the field of health. they oblige the individual to engage in constant risk management. lifestyle and now. normalisation. An ethics is engineered into the molecular make up of these drugs. and to act upon themselves in the light of this belief. and the drugs themselves embody and incite particular forms of life in which the ‘real me’ is both ‘natural’ and to be produced. disseminated in the search for biovalue. of course. So it makes sense to ask whether general practitioners. school or factory – today control is continuous and integral to all activities and practices of existence. specific norms.

Spain. Belgium. However. Ireland. Brazil. Harvard University Press. Colombia. depressants and some analgesics that have medical and scientific uses but can also be drugs of abuse – international comparative data is published annually in the reports on psychotropic substances of the International Narcotics Control Board Now available on line at http://www. Greece). Austria. and would like to thank Robin Keat. it is possible to obtain roughly consistent figures for the period commencing in 1980 by the Government Statistical Service and they kindly provided us with a breakdown of their data. 1997. Japan. Italy. In this paper. Finland. Like all who investigate this area. France. 2002. my work follows lines of enquiry first opened up by David Healy. Notes 1. these data do not include most antidepressants or antipsychotic drugs: for that. and my argument is indebted to his work. South America (Argentina. Angelique Praat. and to see psychiatric drugs as a first line intervention. Venezuela). Thanks to our researcher. stimulants. in manuscript. Germany. Europe (UK. If we are experiencing a ‘neurochemical’ reshaping of personhood’. one has to go to commercial organizations providing data to the drug companies themselves. Mexico. I also draw upon a survey commissioned for that study from IMS Health. For drugs that are listed in the schedules of the UN Convention on Psychotropic Substances of 1971 – hallucinogens. Portugal. detailed in footnote 2 below.org/. funded by the Wellcome Trust Programme in Biomedical Ethics based in the Department of Sociology at Goldsmiths College. we commissioned a customised study from IMS Health based on the data that they compile from over 120 countries. and by ourselves – to the continuous work of modulation of our capacities that is the life’s work of the contemporary biological citizen. Pete Stephens and Ian Webster of IMS in particular for their help and advice data. These data provided the basis for calculations made by our team. To access this data. South Africa (data for other countries in Sub- .incb. For these drugs are becoming central to the ways in which our conduct is problematized and governed.29 Biotechnology between Commerce and Civil Society experience in terms of this simplistic model of mental ill health as a disorder of neurotransmitters. for her work on the collection and analysis of some of this material. Luxembourg. I would also like to thank him for letting me see The Creation of Psychopharmacology. University of London. not merely for symptom relief but as specific treatments for these neurochemical anomalies. drugs prescribed in hospital and sold through retail outlets. I draw upon data collected by myself and Mariam Fraser for our study ‘The Age of Serotonin’. 2. and includes. Uruguay. The best historical work on the development of psychopharmacology has been done by David Healy. and IMS has no responsibility for these or our interpretations. Harvard University Press. by others. Netherlands. which we use in this analysis. The regions chosen for this study are USA. To see in this way is to imagine the disorder as residing within the individual brain and its processes. 3. the social and ethical implications for the twenty first century will be profound. For the UK. and I draw extensively on this here: notably The Antidepressant Era. Peru. for the countries chosen.

but it is far from perfect. For technical reasons. for oral solid forms the standard unit factor is one tablet or capsule whereas for syrup forms the standard unit factor is one teaspoon (5 ml) and injectable forms it is one ampoule or vial. 11. charts and figures are our own. data on medications obtained on a prescription basis are obviously rather limited. 6.S. or any. appliance contractors dispensing doctors and prescriptions submitted by prescribing doctors for items personally administered.. SUs are determined by taking the number of counting units sold divided by the standard unit factor which is the smallest common dose of a product form as defined by IMS Health. Our principle comparative measure is the Standard Dosage Unit (SU). U. and 2000 covers the four quarters from July 2000 to June 2001. Dates shown are calendar years except for the two most recent years . For example. as they refer to drugs obtained on prescription. not those available over-the-counter (OTC) – hence if a drug or group of drugs moves from prescription status to OTC status. it ceases to appear in the figures. And aggregated data conceals significant variations. New products and changes in utilization . 775. There are therefore some risks to using SUs for comparative purposes over the time periods and the regions reported here. For the 1970 figures. prescription drug sales increased by 14. to do with a change in counting methods. This is the best available measure for comparative purposes.Becoming Neurochemical Selves 30 4. such as the anti-convulsants. Shorter uses Parry et al. as they show prescribing practices rather than consumption practices and we know that consumers often do not take all. Figures for 1980-90 are based on fees and on a sample of 1 in 200 prescriptions dispensed by community pharmacists and appliance contractors only. Figures credited to IMS Health are based on that report. are not included. these figures refer to the period for the twelve months to July 2000. 5. For example a 30 day pack of a product given 4 times a day will contribute 120 SUs for each pack sold whereas a similar pack of a once daily product will contribute only 30 SUs. but the analysis. Also it should be noted that in 2000 alone. Earlier comparable figures are not available.for technical reasons arising from IMS data techniques. For the later figures he uses data from the National Center for Health Statistics Vital and Health Statistics in various years. Some drugs used to treat psychiatric conditions. 1973: 769-783. Note that the data up to 1990 are not consistent with data from 1991 onwards. Many more products now have once daily dosing regimes than in the past. Prices refer to total sales ex-manufacturer (not retail prices) in US dollars at the exchange rate at the date in question. 8. Figures from IMS Health. Saharan Africa was not available) and Pakistan (12 year data for India was not available). even these data are affected by national policies. Of course. 1999 covers the four quarters from July1999 to June 2000. Figures for 1991 onwards are based on items and cover all prescriptions dispensed by community pharmacists. In such circumstances SU analyses can make it appear that the market has collapsed even though the days of treatment will have remained constant or increased. Of course.7 percent. and where these are of particular relevance we have tried to supplement SUs with other measures. of the drugs they are prescribed. Leonard claims that the first report was by Schoneker within five years of the introduction of the neuroleptics. as most prescriptions for such drugs are for non-psychiatric conditions. 7. 10. 9.

12.rxlist. DSM IV distinguishes Mood Disorders.8. Whilst marketing strategies tend to avoid coding the anxiety disorders as forms of depression. 25.8. Listed on the Rx List at http://www.rxlist.com/bw/020607/72033_2. 15.htm.02. Alan (2002) ‘The drug companies' latest marketing tactic: "disease awareness" pitch--a new licence to expand drug sales’.com/David-John-Hawkins. see also the resignation letter of leading American social psychiatrist from ‘The American Psychopharmaceutical Association: Lauren Mosher.paxil.8.ca/publications/articles/article315. but for mild to moderate depression.cfm. at http://www. 14.8. http://www.html.policyalternatives. 24.htm.02 http://www. Cassels.nami.htm. 12.8.8 percent increase in drug expenditure while price inflation accounted for 3. and it is in this fuzzy area that the new links between depression and anxiety are being established. not depression.8.02. 22. Prozac has slipped well down the list.8. 12.com/index.cfiwest.8 percent (IMS America.cfm?StoryID=8819419&full=1: 15.html. Healy 1997. .02 http://www.nami.oikos.org/helpline/depress. Resignation letter to APA.com/public/pubs/tcp/1997/oct/ssri.ascp. 13.com/top200.31 Biotechnology between Commerce and Civil Society 12. 20.htm. With the end of its patent and the proliferation of alternative formulations of fluoxetine.com/cgi/generic/parox_cp. 12. http://www.com/dg/1f8182.8.02 http://www.org/mosher. 12. 12.org/illness/whatis.htm. has been until recently the exemplary pathology in Japan. psychiatrists themselves tend to see them as closely linked conditions. 16.antidepressantsfacts.htm A 1997 review of these effects can be found on the website of the American Society of Consultant Pharamcisits http://www.02 We have already seen that anxiety. 12.02 http://www. http://biz.com/pharm_market/prac_guides.html.02. the SSRI drugs were not marketed in the first instance for major depression or bipolar disorder.yahoo.02.htm.pmlive. Quoted at http://www.02. accounted for a 10.org/sos/newsletter/about.8. which include the major depressive disorders.8.pslgroup.02 On the Doctor’s Guide website. 19.02. 21.html: 15.8. 1998: at http://www.html. from Anxiety Disorders. Of course.8. 12. 12. 23. http://www. http://www.com/ccis/news_story. 18. 17. 2000). 12.biospace..

British Medical Journal. Burleigh. (Also available at http://www. MA: Harvard University Press. Meeting on the training of health care professionals in rational prescribing. Breggin. (1988) Psychoactive drugs. Bierman. London: Fontana Brown.ahrq. Phil (1985) The transfer of care : psychiatric deinstitutionalization and its aftermath.’ in Deleuze. 161: 214-217. David (1997) The Antidepressant Era. New York: Farrar Straus Giroux. ——— (2002) The Creation of Psychopharmacology. eds. Elixhauser. 1. MA: Harvard University Press. Moynihan. Healy. Inayat. A.Becoming Neurochemical Selves 32 References American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. 124 (February Supplement): 40. New Brunswick: Rutgers University Press. New York: Grune & Stratton ——— (1967) ‘Persistent dyskinesia: a neurological complication of major tranquilizers. Iona and Henry.’ Medical Science. S (1997). New York: United Nations Publications. Hall. Francis (2002) Our Posthuman Future: Consequences of the Biotechnology Revolution. A. Cambridge. Peter (1993) Toxic Psychiatry. 886-890. Chichester: Wiley. Leonard. (1992) Fundamentals of Psychopharmacology.’ Journal of the American Medical Association. Cambridge. Negotiations. Frank J. ed. Toronto: Addiction Research Foundation. George E. Deleuze. Hospitalization in the United States: Healthcare Cost & Utilization Project (HCUP) Fact Book No. New York: Columbia University Press. . Cambridge: Cambridge University Press. ——— 1994) Diagnostic and Statistical Manual of Mental Disorders. Henry L. Ruth Cooperstock. Gelman. K. (1956) ‘Neurotoxic reactions resulting from chlorpromazine administration.gov/data/hcup/factbk1/) Fukuyama. Rockville. Steiner.’ American Journal of Psychiatry. C. 321. Paris: Odile Jacob. Lennard. Arnold (1974) ‘Perspectives on the New Psychoactive Drug Technology. translated by M. Ray. Ayd. Gilles (1995) ‘Postscript to ‘Societies of Control. with essentials of management and treatment. 1994. 18: 32.. (1961) Recognizing the depressed patient. (1968) ‘Tardive dyskinesia in patients treated with major neuroleptics: a review of the literature. Geneva: World Health Organisation. improving prescribing practices. International Narcotics Control Board (1997. Alain (2000) La Fatigue d’etre soi. Ehrenberg. Hamid and Khan. Third Edition. Boston: Routledge & Kegan Paul. Brian E. Sheldon (1999) Medicating Schizophrenia: A History. Yu. et al. Michael (1994) Death and Deliverance.’ in Social Aspects of the Medical Use of Psychotropic Drugs. Crane. Robert A. 1998. 2000) Report of the International Narcotics Control Board for various years. Heath. Revised (DSM-III-R). Joughin. and Bernstein. Ghodse. New York: American Psychiatric Association. MD: Agency for Healthcare Research and Quality. David (2002) ‘Selling sickness: the pharmaceutical industry and disease mongering’. New York: American Psychiatric Association.

in Essays on the Anthropology of Reason. United States. MD: National Center for Health Statistics. Princeton: Princeton University Press. J. Gregory (2002) Redesigning Humans: our inevitable genetic future.33 Biotechnology between Commerce and Civil Society Moynihan. 28: 769-783. William (1972) The Trade in Lunacy. London: Routledge. an anatomy of depression. Hyattsville. 2002. Andrew (2001) The Noonday Demon. A History of Psychiatry. Hyattsville. Nikolas (2000) ‘Genetic risk and the birth of the somatic individual. J. MD: National Center for Health Statistics (also available at http://www. Smith. British Medical Journal. London: Wiley.htm) Novas. 28: 463. and Hall. R. et al. Parry Jones. New Hope.’ Economy and Society. Shorter. Micky (1991) A Social History of the Minor Tranquilizers. Popovic. Paul (1996) Severing the Ties: Fragmentation and Dignity in Late Modernity. 4: 485-513. World Health Organisation (2001) The World Health Report 2001: Mental Health: New Understanding. E. London: Cape Task Force (1973) ‘A special report. 326. Solomon. Carlos and Rose. Hugh J.319. National Center for Health Statistics (2002) Health. a memoir of madness. (1999) National Hospital Discharge Survey. Advance data from health and vital statistics.gov/nchs/products/pubs/pubd/hus/02hustop.’ Archives of General Psychiatry. London: Chatto and Windus. Parry. Binghampton. 45-47. M. Boston: Houghton Mifflin.’ Archives of General Psychiatry. (1973) ‘National patterns of psychotherapeutic drug use. Stock.cdc. William (1991) Darkness Visible. 29. Rabinow. Styron. 1997. NY: Pharmaceutical Products Press. Geneva: World Health Organisation . no. Ray (2003) ‘The making of a disease: female sexual dysfunction’.

2 4.8 De fin ed in Da ha ily bit Do an se ts pe pe r r 10 da 00 y 8.6 7.000 1.000 population (thousands) 2 1.4 0.000 1.8 2.000 1 3.000 1.Becoming Neurochemical Selves 34 FIGURES Figure Figure 3 Calculated Daily Consumption of Amphetamine per 1000 Psychiatric drug prescribingselectedstandard dosage in 2000 in units per(Source: UNpopulation in selected regions 2000) 100.2 0 1993-1995 Year USA Canada Israel Australia UK and NI New Zealand Norway Chile South Africa Iceland Sweden A US pe ro Eu h ut So Am n pa Ja an st ki Pa h ut So ric Af ica er a 1994-1996 1996-1998 .000 1. (Source: IMS Health) Psychostimulants Hypnotics and Sedatives Tranquilizers Antipsychotics Antidepressants SUs per 100.000 6.000 Narcotics Control Board 1997.4 5.6 0 0.000 0.000 0. 1998.

19 8 8 .35 Biotechnology between Commerce and Civil Society Figure 4 Prescriptions for psychoactive drugs (millions) in the United Kingdom 1960-1985 ( ap p r o xi mat e f i g ur es. Lo nd o n) 30 Num ber of prescriptions (m illions) 25 20 Tranqulizers Hyp not ics 15 10 5 0 1960 1965 1970 1975 1980 1985 Year St imulants A ntidepressant s . r ed r a w n f r o m F i g ur e 1 o f G ho se and Kha n. d e r iv ed mai nl y f r o m t he O f f i ce o f He al t h E co no mic s.

0 Prescription Items (thousands) 20.000.0 Drug s Us ed In Ps ycho s es & Rel.0 1980 1982 1984 1986 1988 1990 1992 Year 1994 1996 1998 2000 .000.000.000.000.0 Hyp no t ics And Anxio lyt ics 15.Becoming Neurochemical Selves 36 Figure 5 Psychiatric drug prescribing (England) 1980-2000 (number of prescription items dispensed in thousands) (Source: Government Statistical Service) 30.0 25.0 St imulants (d examp het amine and methylp henid at e) 0.000.Dis o rd ers Antid ep res s ant Drug s 10.0 5.

37 Biotechnology between Commerce and Civil Society Figure 6 USA: Psychiatric drug prescriptions filled in US drugstores 1964-1980 (Source: M. A Social History of the Minor Tranquilizers ) 250 Prescriptions (millions) Antipsychotics Antianxiety Antidepressants 200 150 100 50 0 1964 1966 1968 1970 1972 1974 1976 1978 1980 Stimulants Sedatives Hypnotics Total Year . 1991. Smith.

000 6.000 2.000 Sales in USD (millions) 16.000 10.000 18.000 12.Becoming Neurochemical Selves 38 Figure 7 USA: Psychiatric drug sales 1990-2000 in US Dollars (Souce: IMS Health) 20.000 14.000 8.000 4.000 0 1990 1992 1994 1996 Year 1998 1999 2000 Total Antidepressants Antipsychotics Tranqulizers Hypnotics and Sedatives Psychostimulants .

000 5.000 Standard Units (millions) Total 20.000 15.39 Biotechnology between Commerce and Civil Society Figure 8 USA: Psychiatric drug prescribing 1990-2000 in Standard Units (Source: IMS Health) 25.000 Antidepressants Antipsychotics Tranquilizers 10.000 0 1990 1992 1994 1996 Year 1998 1999 2000 Hypnotics and Sedatives Psychostimulants .

000 6.000 8.000 5.000 9.000 3.000 4.000 1.000 2.Becoming Neurochemical Selves 40 Figure 9 A ntidepressant Prescribing USA 1990-2000 in SUs (Source: IMS Health) 10.000 7.000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Year Standard Units (Millions) Ant idepr essant s-A ll SSRI ant idepr essant s All Ot her Ant idepr essant s .

400 1.000 800 600 400 200 0 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 Standard Units (millions) ALL METHYLPHENIDATE DEXAMPHETAMINE AMPHETAMINE Year .800 1.600 1.200 1.41 Biotechnology between Commerce and Civil Society Figure 10 Psychost imulant Prescribing in t he USA in St andard Unit s (Source: IMS Health) 2.000 1.

5 2 1.5 1 0.5 3 2.5 0 1993-1995 1994-1996 Year 1996-1998 USA Canada Israel Australia UK and NI New Zealand Norway Chile South Africa . 1998.Becoming Neurochemical Selves 42 Figure 11 Calculated Daily Consumption of Methyphenidate per 1000 inhabitants in selected regions (Source: UN Narcotics Control Board 1997. 2000) 4 Defined Daily Doses per 1000 inhabitants per day 3.

43 Biotechnology between Commerce and Civil Society .

Becoming Neurochemical Selves 44 Figure 13 Psychiatric Drug Prescribing in Selected Regions Proportions prescribed 2000 in different therapeutic classes (SU per 100000 popn) (Source: IMS Healt h) 70.0 10.0 20.0 Percentage 40.0 0.0 30.0 50.0 60.0 USA Europe Japan South A merica Sout h A frica Pakist an Antidepressants Antipsychotics Tranquilizers Hypnotics and Sedatives Psychostimulants Region .

45 Biotechnology between Commerce and Civil Society Figure 14 Lustral: “The choice is simple – with bright prospects in mind” British Journal of Psychiatry 1991 .

Becoming Neurochemical Selves 46 Figure 15 Prozac: The Prozac Promise American Journal of Psychiatry 1995 .

sexual side effects. PAXIL works to correct this imbalance to relieve anxiety. At home I’m tense about stuff at work Female narrator If you are one of the millions of people who live with uncontrollable worry. NOW HAPPY AND PLAYING WITH CHILDREN. Symptoms roll across the screen: WORRY … ANXIETY … MUSCLE TENSION … FATIGUE … IRRITABILITY … RESLESSNESS … SLEEP DISTURBANCE … LACK OF CONCENTRATION you could be suffering from Generalized Anxiety Disorder and a chemical imbalance could be to blame. tremor or sleepiness. sweating. constipation. it just goes over and over… I just always thought I was a worrier Caption THE REAL STORY ABOUT CHRONIC ANXIETY Male character: Its like I never get a chance to relax. IMAGES OF PREVIOUS CHARACTERS. anxiety and several of these symptoms…. the what ifs … I can’t control it. and I’m always worrying about everything Female character 3: Its like a tape in your mind. dry mouth. Side effects may include decreased appetite.47 Biotechnology between Commerce and Civil Society Figure 16 Paxil: “The real story about chronic anxiety” American Television October 1991 Female Character 1: I’m always thinking something terrible is going to happen. nausea. I feel like me again. WASHING CAR ETC. I can’t handle it Female Character 2: You know. At work I’m tense about stuff at home. Paxil is not habit forming Female character 1: I’m not bogged down by worry anymore. your worst fears. I feel like myself . WHILST NARRATOR RUSHES THOUGH LIST OF SIDE EFFECTS Prescription Paxil is not for everyone… Tell your doctor what medicines you are taking….

000 200.000 600.000 1.000.400.000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 FLUOXETINE SERTRALINE PAROXETINE VENLAFAXINE CITALOPRAM MIRTAZAPINE FLUVOXAMINE Year .000 SUs (thousands) 1.200.Becoming Neurochemical Selves 48 Figure 17 SSRI and related drug prescribing USA 1990-2001 Source: IMS Health SSRI and Related Drug Prescribing USA 1990-2000 in SUs (Source: IMS Health) 1.000 800.000 400.

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