Anatomy of an Epidemic (7 page)

The United States geared up for this wondrous future. Prior to the war, most basic research had been privately funded, with Andrew Carnegie and John D. Rockefeller the most prominent benefactors, but once the war ended, the U.S. government established the National Science Foundation to federally fund this endeavor. There were still many diseases to conquer, and as the nation’s leaders looked around for a medical field that had lagged behind, they quickly found one that seemed to stand above all the rest. Psychiatry, it seemed, was a discipline that could use a little help.

As a medical specialty, psychiatry had its roots in the nineteenth-century asylum, its founding moment occurring in 1844, when thirteen physicians who ran small asylums met in Philadelphia to
form the Association of Medical Superintendents of American Institutions for the Insane. At that time, the asylums provided a form of environmental care known as moral therapy, which had been introduced into the United States by Quakers, and for a period, it produced good results. At most asylums, more than 50 percent of newly admitted patients would be discharged within a year, and a significant percentage of those who left never came back. A nineteenth-century long-term study of outcomes at Worcester State Lunatic Asylum in Massachusetts found that 58 percent of the 984 patients discharged from the asylum remained well throughout the rest of their lives. However, the asylums mushroomed in size in the latter part of the 1800s, as communities dumped the senile elderly and patients with syphilis and other neurological disorders into the institutions, and since these patients had no chance of recovering, moral therapy came to be seen as a failed form of care.

At their 1892 meeting, the asylum superintendents vowed to leave moral therapy behind and instead utilize physical treatments. This was the dawn of a new era in psychiatry, and in very short order, they began announcing the benefits of numerous treatments of this kind. Various water therapies, including high-pressure showers and prolonged baths, were said to be helpful. An injection of extract of sheep thyroid was reported to produce a 50 percent cure rate at one asylum; other physicians announced that injections of metallic salts, horse serum, and even arsenic could restore lucidity to a mad mind. Henry Cotton, superintendent at Trenton State Hospital in New Jersey, reported in 1916 that he cured insanity by removing his patients’ teeth. Fever therapies were said to be beneficial, as were deep-sleep treatments, but while the initial reports of all these somatic therapies told of great success, none of them stood the test of time.

In the late 1930s and early 1940s, asylum psychiatrists embraced a trio of therapies that acted directly on the brain, which the popular media—at least initially—reported as “miracle” cures. First came insulin coma therapy. Patients were injected with a high dose of insulin, which caused them to lapse into hypoglycemic comas, and when they were brought back to life with an injection of glucose, the
New York Times
explained, the “short circuits of the brain
vanish, and the normal circuits are once more restored and bring back with them sanity and reality.”
⁷
Next came the convulsive therapies. Either a poison known as Metrazol or electroshock was used to induce a seizure in the patient, and when the patient awoke, he or she would be free of psychotic thoughts and happier in spirit—or so the asylum psychiatrists said. The final “breakthrough” treatment was frontal lobotomy, the surgical destruction of the frontal lobes apparently producing an instant cure. This “surgery of the soul,” the
New York Times
explained, “transforms wild animals into gentle creatures in the course of a few hours.”
⁸

With such articles regularly appearing in major newspapers and magazines like
Harper’s, Reader’s Digest
, and the
Saturday Evening Post
, the public had reason to believe that psychiatry was making great strides in treating mental illness, participating in medicine’s great leap forward, but then, in the wake of World War II, the public was forced to confront a very different reality, one that produced a great sense of horror and disbelief. There were 425,000 people locked up in the country’s mental hospitals at that time, and first
Life
magazine and then journalist Albert Deutsch, in his book
The Shame of the States
, took Americans on a photographic tour of the decrepit facilities. Naked men huddled in barren rooms, wallowing in their own feces. Barefoot women clad in coarse tunics sat strapped to wooden benches. Patients slept on threadbare cots in sleeping wards so crowded that they had to climb over the foot of their beds to get out. These images told of unimaginable neglect and great suffering, and at last, Deutsch drew the inevitable comparison:

The nation clearly needed to remake its care of the hospitalized mentally ill, and even as it contemplated that need, it found reason to worry about the mental health of the general population. During the war, psychiatrists had been charged with screening draftees for psychiatric problems, and they had deemed 1.75 million American men mentally unfit for service. While many of the rejected draftees may have been feigning illness in order to avoid conscription, the numbers still told of a societal problem. Many veterans returning from Europe were also struggling emotionally, and in September 1945, General Lewis Hershey, who was the director of the Selective Service System, told Congress that the nation badly needed to address this problem, which had remained hidden for so long. “Mental illness was the greatest cause of noneffectiveness and loss of manpower that we met” during the war, he said.
¹⁰

With mental illness now a primary concern for the nation—and this awareness coming at the very time that antibiotics were taming bacterial killers—it was easy for everyone to see where a long-term solution might be found. The country could put its faith in the transformative powers of science. The existing “medical” treatments said to be so helpful—insulin coma, electroshock, and lobotomy—would have to be provided to more patients, and then long-term solutions could arise from the same process that had produced such astonishing progress in fighting infectious diseases. Research into the biological causes of mental illnesses would lead to better treatments, both for those who were seriously ill and those who were only moderately distressed. “I can envisage a time arriving when we in the field of Psychiatry will entirely forsake our ancestry, forgetting that we had our beginnings in the poorhouse, the workhouse and the jail,” said Charles Burlingame, director of the Institute of the Living in Hartford, Connecticut. “I can envisage a time when we will be doctors, think as doctors, and run our psychiatric institutions in much the same way and with much the same relationships as obtain in the best medical and surgical institutions.”
¹¹

In 1946, Congress passed a National Mental Health Act that put the federal government’s economic might behind such reform. The government would sponsor research into the prevention, diagnosis, and treatment of mental disorders, and it would provide grants to
states and cities to help them establish clinics and treatment centers. Three years later, Congress created the National Institute of Mental Health (NIMH) to oversee this reform.

“We must realize that mental problems are just as real as physical disease, and that anxiety and depression require active therapy as much as appendicitis or pneumonia,” wrote Dr. Howard Rusk, a professor at New York University who penned a weekly column for the
New York Times
. “They are all medical problems requiring medical care.”
¹²

The stage had now been set for a transformation of psychiatry and its therapeutics. The public believed in the wonders of science, the nation saw a pressing need to improve its care of the mentally ill, and the NIMH had been created to make this happen. There was the
expectation
of great things to come and, thanks to the sales of antibiotics, a rapidly growing pharmaceutical industry ready to capitalize on that expectation. And with all those forces lined up, perhaps it is no surprise that wonder drugs for both severe and not-so-severe mental illnesses—for schizophrenia, depression, and anxiety—soon arrived.

The “magic bullet” model of medicine that had led to the discovery of the sulfa drugs and antibiotics was very simple in kind. First, identify the cause or nature of the disorder. Second, develop a treatment to counteract it. Antibiotics killed known bacterial invaders. Eli Lilly’s insulin therapy was a variation on the same theme. The company developed this treatment after researchers came to understand that diabetes was due to an insulin deficiency. In each instance, knowledge of the disease came first—that was the magic formula for progress. However, if we look at how the first generation of psychiatric drugs was discovered, and look too at how they came to be called
antipsychotics, anti-anxiety
agents, and
antidepressants
—words that indicate they were antidotes to specific disorders—we see a very different process at work. The psychopharmacology revolution was born from one part science and two parts wishful thinking.

The story of the discovery of Thorazine, the drug that is remembered today as having kicked off the psychopharmacology “revolution,” begins in the 1940s, when researchers at Rhône-Poulenc, a French pharmaceutical company, tested a class of compounds known as phenothiazines for their magic-bullet properties. Phenothiazines had first been synthesized in 1883 for use as chemical dyes, and Rhône-Poulenc’s scientists were trying to synthesize phenothiazines that were toxic to the microbes that caused malaria, African sleeping sickness, and worm-borne illnesses. Although that research didn’t pan out, they did discover in 1946 that one of their phenothiazines, promethazine, had antihistaminic properties, which suggested it might have use in surgery. The body releases histamine in response to wounds, allergies, and a range of other conditions, and if this histaminic response is too strong, it can lead to a precipitous drop in blood pressure, which at the time occasionally proved fatal to surgical patients. In 1949, a thirty-five-year-old surgeon in the French Navy, Henri Laborit, gave promethazine to several of his patients at the Maritime Hospital at Bizerte in Tunisia, and he discovered that in addition to its antihistaminic properties, it induced a “euphoric quietude…. Patients are calm and somnolent, with a relaxed and detached expression.”
²

Promethazine, it seemed, might have use as an
anesthetic
. At that time, barbiturates and morphine were regularly employed in medicine as general sedatives and painkillers, but those drugs suppressed overall brain function, which made them quite dangerous. But promethazine apparently acted only on selective regions of the brain. The drug “made it possible to disconnect certain brain functions,” Laborit explained. “The surgical patient felt no pain, no anxiety, and often did not remember his operation.”
³
If the drug was used as part of a surgical cocktail, Laborit reasoned, it would be possible to use much lower doses of the more dangerous anesthetic agents. A cocktail that included promethazine—or an even
more potent derivative of it, if such a compound could be synthesized—would make surgery much safer.

Chemists at Rhône-Poulenc immediately went to work. To assess a compound, they would give it to caged rats that had learned, upon hearing the sound of a bell, to climb a rope to a resting platform in order to avoid being shocked (the floor of the cage was electrified). They knew they had found a successor to promethazine when they injected compound 4560 RP into the rats: Not only were the rats physically unable to climb the rope, they weren’t emotionally interested in doing so either. This new drug, chlorpromazine, apparently disconnected brain regions that controlled both motor movement and the mounting of emotional responses, and yet it did so without causing the rats to lose consciousness.

Laborit tested chlorpromazine as part of a drug cocktail in surgical patients in June of 1951. As expected, it put them into a “twilight state.” Other surgeons tested it as well, reporting that it served to “potentiate” the effects of the other anesthetic agents, the cocktail inducing an “artificial hibernation.” In December of that year, Laborit spoke of this new advance in surgery at an anesthesiology conference in Brussels, and there he made an observation that suggested chlorpromazine might also be of use in psychiatry. It “produced a veritable medicinal lobotomy,” he said.
⁴

Although today we think of lobotomy as a mutilating surgery, at that time it was regarded as a useful operation. Only two years earlier, the Nobel Prize in Medicine had been awarded to the Portuguese neurologist, Egas Moniz, who had invented it. The press, in its most breathless moments, had even touted lobotomy as an operation that plucked madness neatly from the mind. But what the surgery most reliably did, and this was well understood by those who performed the operation, was change people in a profound way. It made them lethargic, disinterested, and childlike. That was seen by the promoters of lobotomy as an improvement over what the patients had been before—anxious, agitated, and filled with psychotic thoughts—and now, if Laborit was to be believed, a pill had been discovered that could transform patients in a similar way.