Of Two Minds: The Growing Disorder in American Psychiatry
By T.M. Luhrmann
Knopf, 352 pp.

Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives
By Joseph Glenmullen
Simon and Schuster, 320 pp.

Since the 19th century, when psychology and psychiatry emerged as modern "sciences," there has been tension between their spiritual and scientific roots. Early psychologists had to convince skeptical patients that they could fill the spiritual vacuum in their lives, while also fighting to maintain their authority by the new standards of real science--chemistry, biology, and especially medicine.

As the millennium turns, that tension continues. Anthropologist Tanya Luhrmann suggests in her disturbing new book on psychiatry that the scientific roots have been artificially stimulated and are in danger of strangling the spiritual roots altogether.

Unlike other doctors, who deal with what Martin Luther called "inessential suffering," which is separable from who we are, psychiatrists deal with "essential suffering," which is tied up with what makes us human. As Luhrmann puts it, essential suffering involves the "wants, fears, aspirations that are knitted into the person that [a] patient has become." Psychiatrists cannot deal with all of that fully: "That is why there are priests, ministers, and rabbis attached to hospitals." Religion, says Luhrman, can make us come to terms with essential suffering. "We learn to understand pain as part of life... as a spiritual lesson."

Luhrmann believes that the tension between the two "minds" of psychiatry--the biomedical, which treats psychological suffering as inessential, and the psychodynamic, which seeks to grapple with both kinds of suffering--has been a source of its strength. Chemists' discoveries have been as important as the insights of doctors who talk and listen to their patients. Drugs have a good record in recent years in treating what are now understood to be largely organic malfunctions, such as schizophrenia.

But chemistry has not done so well with other kinds of suffering, particularly with the currently fashionable "depression." The vogue of Prozac and other so-called serotonin re-uptake inhibitors has obscured the truth that Luhrmann patiently sets out: in study after study, the new drugs perform no better than old-fashioned "talk therapy" in alleviating the symptoms of depression.

Yet the mania for cost-cutting--i.e., for rofits--in the new managed-care system is squeezing out old-fashioned methods, along with a whole way of thinking about our mental (what used to be called our spiritual) condition.

Luhrmann is remarkably calm about how psychiatry, particularly hospital training, is being hypermedicalized--how the spirit is being taken out of the study and treatment of the psyche. Much of what she reports about the pressures on the young residents she spent years observing is so alarming, and the pharmaceutical and managed care industries are so full of Pollyannas, that a harsher tone would have been warranted, if only to balance the hype put out by drug companies and "researchers" who advocate the new drugs. Perhaps Luhrmann, as an outsider without scientific credentials, felt compelled to be overly polite.

Joseph Glenmullen, clinical instructor at Harvard Medical School and an M.D. fluent in neurochemistry and microbiology, has no such reservations. He indicts the health industry for dangerous malfeasance, presenting evidence that talk therapy is actually more effective than the much-touted new drugs.

Glenmullen criticizes influential "studies" of the new serotonin boosters--often tainted by the researchers' conflicts of interest ("consulting" fees and the like from the companies whose products they aresupposedly evaluating). He concludes that the Prozac-type drugs do no better than older, cheaper drugs, or even cocaine, nicotine, and caffeine. The research published in top journals is often so shoddy, and the reporting so selective, that doctors are often as ill-informed as their patients about new drugs.

Meanwhile, the diminishing number of doctors who are informed are shunted aside. Managed-care companies have shifted decision-making away from psychiatrists (to a far greater extent than they have done with other specialists) toward primary-care physicians. These overworked "gatekeepers" of the managed-care inferno cannot hope to keep up with independent research. They can hardly be blamed when they rely on the pseudoscience that pharmaceutical companies bombard them with.

The most disturbing example Glenmullen describes is the l994 Websecker case, in which Eli Lilly bought off the survivors of a mass homicide apparently committed under the influence of its wonder drug, Prozac. The survivors had sued Eli Lilly, but in an unprecedented breach of legal ethics, the parties to the case made a deal behind the judge's back to suppress evidence and to keep the survivors silent. Then Lilly boasted to the press that the product had been certified safe by the legal system. The truth only came out years later, when one plaintiff's payoff from Lilly became part of the public record in his divorce case. The original trial judge ordered the verdict changed, but there was hardly any publicity about that (it took place when the nation's attention was focused on the O. J. Simpson trial).

Glenmullen documents many other cases of Prozac's grisly side-effects. The "backlash" in his title refers to the compensating drop in dopamine that seems to occur in the brain when serotonin is boosted to abnormal levels. This would seem to explain the dependency that, Glenmullen says, holds unwitting patients "hostage" to the drug, and the withdrawal symptoms that cripple many who try to quit it, impelling many doctors simply to raise their dose, at God knows what long-term risk.

It does not occur to Glenmullen to call the new Prozac-type drugs patent medicines, but the pharmaceutical companies' control of research about their products--along with their artificially high price and commensurate promotion budgets--suggests a new meaning for that term. Glenmullen makes the preachers of salvation through serotonin sound like the Elmer Gantries and Father Divines of an earlier era.

Glenmullen's book is a call to action. Given the economic and political power of the health industry, the mystique of medical "science," and the unique weakness of American government in the health field, he cannot hope for anything as ambitious and sensible as policy change. But perhaps the bad news will get the drug companies where they hurt: the market. Next to the pharmaceutical companies' big guns of advertising and P.R., however, Glenmullen's primitive weapons of evidence and reason look pretty weak.

It is not surprising that Luhrmann, whose values and training as a student of human culture make her skeptical of radically materialist approaches to human souls, finds fault with the pharmacological determinism that has infected the health industry. Her book is a learned, compassionate account of how psychiatrists are increasingly pressured to ignore the wisdom of the ages and their own sensible instincts about human suffering. But Glenmullen's critique of neurochemistry, on its own purely materialistic and scientific terms, is much more damning. If you or someone you love is caught up in the brave new world of managed psychopharmacology, these books may be the wisest investment you can make.

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