Furor Therapeuticus : Benjamin Rush and the Philadelphia Yellow Fever Epidemic of 1793

During the first half of the 20th century, psychiatric teaching and practice were entirely occupied with psychoanalytically oriented psychotherapy to overcome the putative poor parenting that was thought to be responsible for mental disorders. This therapeutic furor was replaced in short order by an equally single-minded commitment to biological psychiatry that continues to occupy our profession to this day. Our current psychotropic drugs and the new biological psychiatry that they have engendered arose from a series of chance discoveries: reserpine’s psychotropic effects when it was used to treat high blood pressure, the use of chlorpromazine as a tranquilizer during research on anesthesia, iproniazid as a euphoriant during the treatment of tuberculosis, the antidepressant properties of imipramine when it was employed as a presumptive antipsychotic, and the antimanic effects of lithium when its urate salt sedated experimental animals. The therapeutic effectiveness of these medicines was established by the newly introduced double-blind, randomized clinical trial. Because the new agents seemed to be relatively syndrome specific, diagnosis and classification suddenly became important for clinical management (7) . Psychiatrists awakened from their overreliance on psychodynamic explanations for schizophrenia to rediscover their medical roots. It became convenient to emphasize licensure for those writing prescriptions; that ability provided an edge in marketplace competition with psychologists and social workers, an edge psychologists are now contesting.

The new medications were given entire credit for the greatly shortened lengths of hospital stays and the successful ambulatory management of psychotic patients. We had failed to understand that the depersonalized and dehumanized mental hospitals had themselves superimposed a “social breakdown syndrome” on the psychiatric disorder that led to the initial admission (8) . Michael Shepherd and his colleagues (9) reexamined patient movement in a Buckinghamshire County catchment area of the United Kingdom during two epochs, 1931–1933 and 1945–1947, well before the introduction of drugs. They demonstrated that shorter stays and higher discharge rates were evident a decade before the drugs made their appearance. The change resulted from the introduction of a socially progressive mental health policy: the open hospital and community services. Under those circumstances, the drugs added relatively little. Psychotropic drugs brought relatively little change in hospitals where discharge rates were high before drug use but led to considerable improvements where predrug discharge rates had been low (10) . Nonetheless, policy and practice stressed drug compliance to the exclusion of almost all other interventions.

Although chlorpromazine, the prototypical first-generation antipsychotic, was unequivocally more effective than placebo or psychotherapy in relieving acute symptoms of schizophrenia and preventing their recurrence, limits to effectiveness and problems with side effects led to a search for “second-generation antipsychotics,” which were greeted with as much enthusiasm as their predecessors and are now shown to be marginally, if at all, superior (11, 12, 13) and far more costly (14, 15) . What is striking is the disparity between the early results, albeit hyped by the pharmaceutical industry, and our willingness to switch almost every patient to these new drugs (16, 17) . The sobering data from current trials, it is hoped, will have provided a brake on this therapeutic enthusiasm.

The furor therapeuticus for drug treatment has included my own subspecialty, child psychiatry. When my professional career began, what is now known as attention deficit hyperactivity disorder (ADHD) was labeled “hyperkinetic behavior disorder” or “minimal brain dysfunction.” There was one symptomatic treatment: dextroamphetamine. Our Hopkins research group received the first National Institute of Mental Health grant for randomized, double-blind trials of psychotropic drugs in children (18) ; we documented the efficacy of stimulants for the treatment of hyperkinesis (19 – 21) . Use of stimulants has exploded in the decades that followed. Although at the 1967 World Health Organization International Seminar on Diagnosis and Classification in Child Psychiatry (22) Michael Rutter and I had to argue forcefully for the inclusion of “hyperkinetic syndrome” as an entity, current psychiatric drug prescription data for 2005, based on an analysis by Medco Health Solutions (23), lists 3.6 million children (under age 19) as taking at least one drug for ADHD, with 28% of those children taking two or more. Does this reflect an epidemic of ADHD or an epidemic of diagnostic and therapeutic fashion?

APA meetings are permeated by pharmaceutical companies’ effective marketing. Our enthusiasm for biological psychiatry leads to prescribing the latest drugs, which are also the most expensive and most heavily marketed. Attendees can enjoy three free meals each day by attending sessions sponsored by pharmaceutical companies and “earn” continuing medical education credits (CME), to boot, for sitting through lectures. Although the talks are nominally certified as nonbiased by APA CME regulations, lecturers all too often use company slides, elegantly produced (and subtly slanted). APA has become increasingly dependent on drug company support for its annual meetings through sponsored lectures, rental space for commercial displays, and subsidy of travel expenses and registration fees for foreign psychiatrists.

Since World War II, psychiatry has undergone wild swings in prevailing opinion (24), from an evidence-free faith in the miracles of psychodynamic psychotherapy to an uncritical belief in the wonders of psychopharmacology (as though patients no longer needed to be listened to), from dismissal of the brain in favor of the mind to a dismissal of mind in favor of the brain (as though they were not inextricably intertwined), from refusal to countenance genetics to worship at its altar (as if there were genes “for” schizophrenia or “for” depression). As an antidote to furor therapeuticus, it is essential that we not forget Sir Aubrey Lewis’s admonition:

An edited version of the Benjamin Rush Lecture on Medical History presented at the 58th Psychiatric Services Institute, New York, Oct. 5–8, 2006. Address correspondence and reprint requests to Dr. Eisenberg, Department of Social Medicine, Harvard Medical School, 641 Huntingdon Ave., #215, Boston, MA 02115-6019; [email protected] (e-mail).

The author reports no competing interests.