In 1954 the first antipsychotic drug, chlorpromazine, appeared. It calmed the acutely disturbed psychotic patient remarkably well. In the decade that followed chemists produced variations, which did much the same, but all had side-effects. They induce a dullness of mind and sleepiness that some dislike so much they prefer to remain mentally ill. All dislike the abnormal movements coupled with restlessness and a sense of unpleasant tension that appear in about a third of cases, the toxic state known as akathisia (see British Journal of Psychiatry editorial). Drugs of the anticholinergic class produce some relief, but not enough to please most patients. At its extreme the toxic state becomes delirium, hardly distinguishable from the psychosis.
In the 1980s a new class of neuroleptics appeared. They became known as second-generation antipsychotics, which their manufacturers advertised as lacking the unpleasant side-effects. Simply saying so did the trick. The new rapidly supplanted the old, their sales escalating rapidly despite their much higher cost. The psychiatrists who took this course justified their choice on the grounds that patients prefer them. In fact the customer had no choice. Two decades later the first thorough studies established that the newer antipsychotics produce no less side-effects than the first and no more therapeutic effect, possibly less. The psychiatrists had seen a non-existent benefit that clever advertising persuaded them to expect (see “Refractory Psychiatry”) and they held the whip hand, or rather the prescriber’s pen. The scientific proof that they are wrong did not correct their vision in the years that followed publication of the reality.
The latest analysis discloses a curious and most revealing anomaly. Although the second-generation antipsychotics produce just as much akathisia as the first, psychiatrists prescribed 30 times less anticholinergic medication than they did with the first generation. They failed to see the ill effects they were told did not occur and consequently did not treat them. The advertising had not only made them see the vaunted but non-existent benefits, but blinded them to the denied ill effects, mental dulling and akathisia. What separates the therapists from the mad? Oddly enough a quality all sane people possess, a vulnerability to mass persuasion. The mad on the other hand pursue their delusions in idiosyncratic isolation.
Memes shape perception and memory in their own image. I am reminded of a view that appeared about the time that community psychiatry began and the asylums discharged their residents en masse. Academic psychiatry allayed the alarm of the community by asserting that the mentally ill pose no danger. They produced statistics to show that the insane have a lower propensity to violence than the sane. And psychiatrists continued to find it true for the next 50 years. Now the academics (see Paul Mullen) who discuss the difficulty of predicting dangerousness ponder on how they could have failed to see the reality for so long. If highly educated psychiatrists can be so inane, what trust can the insane and their families have in the decisions that make life unpleasant for them? Has education made psychiatrists peculiarly gullible to marketing or, the view I prefer, they share the vulnerability of all educated humans to meme tyranny?