The Creation of Psychopharmacology

This is a book about the history and development of antipsychotics since the advent of chlorpromazine. It covers the political, sociologic, and economic factors that influenced antipsychotic drug development.

I had a very mixed reaction to The Creation of Psychopharmacology. Certain parts of the book are wonderful. The history of antipsychotics is covered in depth and detail and is a good read. This segment brings to life the history of chlorpromazine in a way that includes the zeitgeist of psychiatry and society during this era of pharmacologic breakthroughs in the treatment of schizophrenia. We are introduced to the human side of the story—the temperamental French psychiatrist Delay, who first called these drugs neuroleptics, and the American psychiatrist Nathan Kline, who single-handedly promoted psychopharmacology as a discipline. One of the strengths of the book is Healy's extensive study of the other influences in the field at the time. We learn about how new drugs such as chlorpromazine replaced insulin coma therapy. We learn about the rise and fall of the transmethylation hypothesis of schizophrenia and about how the dopamine hypothesis came to eclipse other theories of schizophrenia.

The book has some serious flaws that need to be mentioned. My first concern is that the book distorts some of the facts so that they conform to the opinions and speculations of the author—for example, that withdrawal dyskinesia associated with antipsychotics constitutes "antipsychotic dependence" and that "the failure of buspirone . . . led to a switch from developing anxiolytics to developing SSRIs [selective serotonin reuptake inhibitors] as antidepressants." Healy is very idiosyncratic in his interpretation of clinical trials data. He has an axe to grind against SSRIs: "The FDA licensed fluoxetine, on the basis of its minimal superiority to placebo and its inferiority to imipramine." Elsewhere, he is much more sympathetic to insulin coma therapy: "Insulin coma therapy clearly worked in a number of senses, as the clinical trial evidence suggests." It is hard to imagine that the results of clinical trials can really reconcile the book's scathing view of SSRIs with the favorable interpretation of insulin coma therapy.

One glaring problem is the author's bias in the citations, which have been handpicked or misused to support his conclusions. The citation biases will not be obvious to readers who are not thoroughly familiar with the specific details or sources of the material. For example, Healy believes that claims of benefits of atypical antipsychotics in terms of extrapyramidal effects are the result of the excessive dosing of high-potency conventional antipsychotics used in clinical trials. Fair enough. To support his point, he reports—but does not cite—a comparison study of different doses of haloperidol and the atypical antipsychotic sertindole (1). The text reads "Sertindole was in fact no better than haloperidol at 8 mg a day, and both haloperidol at 8 mg a day and sertindole were better than haloperidol at 16 mg a day." However, that study showed that therapeutic doses of sertindole were associated with fewer extrapyramidal effects than a low dose of haloperidol (4 mg a day). I was able to find many other examples of incomplete citations and misleading conclusions. The reader needs to be much better informed of the author's biases and should be very skeptical in accepting the "facts" as they are presented.

Dr. Healy's provocative conclusions are thought-provoking. The Creation of Psychopharmacology is certainly not boring, and that helps to keep the historical material interesting. But, time and again, the book is misleading to the point of being deceptive. Having controversial opinions is not necessarily a problem, but misleading the reader about the facts is a serious problem.

In summary, The Creation of Psychopharmacology is a fascinating journey into the history of antipsychotic medications and a thought-provoking critique of our understanding of psychiatric drugs and the pharmaceutical industry. However, the book is more like a manifesto than a balanced historical review. With its authoritative tone and extensive citations, it should not be considered an accurate rendition of the early history of psychopharmacology.