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3.9 What passes for progress

What progress has in fact been made in treating depression with the coming of the SSRIs ? In the opinion of many of the great names in this field, the answer appears to be very little, hardly enough to justify the hard sell of the manufacturers and the leadership in clinical medicine.

  • "In my opinion, if you look at the history of psychopharmacology , since, say, 1964 - thirty years now - nothing radically new has been introduced. Perhaps the only original idea was the discovery by Japanese colleagues that a drug such as carbamezepine, used as an anti-epileptic, could be protective in manic-depressive disease" (Pichot, 1996)

    " ... it seems almost that the era of drug discovery is over ...The golden era was 1954 through 1974 or thereabouts. In the last 20 years, there have been great advances in neuroscience but not clinical advances to anything like the same extent." ... " We have gone 30 years without really discovering much." (Healy, 1996)

    "We had the monoamine oxidase inhibitors and in 1959 we have the first tricyclic antidepressant. There has been no important progress after 1959. Some differences in the mechanism of action but equivalence in potency. Maybe smaller differences in side effects which have not been exploited in clinical practice. Clozapine may represent a progress in the treatment of the psychoses but that’s all." (Garattini, 1996)

    "Not much has changed in practice. We know how to do it faster and a little better but the modus of doing it has not changed" ... "As regards treatment, I think we probably have enough on the shelves to serve us for some time if we learn how to use it". (Lehmann, 1996)

    " ... It’s notable isn’t it, there haven’t been many new ideas in psychopharmacology in the last decade." (Coppen, 1996)

    "We have made great strides in reducing side effects and toxicity but as far as clinical efficacy is concerned we have really made very little progress." (Beaumont, 1996)

    "...if you really want to reduce the thing to basics, the discoveries which opened the path for the development of modern psychiatry are the discoveries of the effects of chlorpromazine, lithium, imipramine, and meprobamate ... With all fairness to the vast array of drugs which followed, the best any of these drugs have done is to substitute one side effect for another, while creating by their rapidly growing number a tremendous turmoil for physicians, and by their steadily increasing cost a serious financial burden for patients." (Ban, 1996)

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    These opinions were given in interviews recorded in the mid-1990s by Dr. David Healy, a practising psychiatrist and historian of medicine. They are not only fascinating; along with other papers by Healy, they have also have much influenced the thinking in this paper. The truth may indeed be that not much has really changed since the introduction of the first antidepressants - whose own effectiveness was still in doubt, even ten years on. Though widely praised and used, in those days it was still not transparently silly to be asking "Are antidepressants better than placebo?" (Malitz & Kanzler, 1971), nor to suggest "Yes, but barely" as a likely answer. (Hollister, 1972)

    The last word on progress belongs to Lewis Thomas (1979), with a thought which just predates the age of the SSRIs: progress in medicine and in securing health come from good science and good sense. In the absence of either, it is wiser to desist:

    "My contention is that we do have some science in the practice of medicine, but not anything like enough, and we have a great distance to go. And, although we have achieved, through the application of science, a degree of mastery over many infectious diseases formerly responsible for great numbers of premature deaths, the introduction of science into medicines did not really begin with the management of infection. Long before that event, some time in the middle of the nineteenth century, medicine showed its first signs of scientific insight by undergoing quite a different sort of professional transformation. It stopped doing some things."

    New products and perceived breakthroughs do not necessarily bring real progress. The history of dependence on sedative-hypnotic drugs over the past 200 years strongly supports the view that medicine sometimes makes real progress not by leaping forward, but by looking back. At present, as in the past, good medicine involves learning from mistakes and not repeating them. "The greatest mistakes are probably made not because doctors don’t know enough, but because too often they behave as if they do" [Medawar, 1996].

    On the face of it, government and regulatory authorities, the leadership of the medical profession and the pharmaceutical industry have much to answer for. From early 1998, their response and further information and debate on this matter will be reported on the Internet (http://www.socialaudit.org.uk).

    Charles Medawar
    Social Audit Ltd
    August, 1997
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