The so-called ‘new generation’ antidepressants - Prozac chief among them - have had arguably the biggest impact on the public consciousness of any new drug. Debate about the pros and cons of the medication generated unprecedented media interest. But what exactly happened? How and why did Prozac arrive when it did, and what does it tell us about where psychiatry, and public understanding of mental health, might be headed?

Nikolas Rose, Professor of Sociology at Goldsmiths College, London, has been involved “conceptually and practically” with psychiatry since the 1960s, when he took a first degree in biology and psychology at Sussex, and became interested in the burgeoning radical psychiatry movement. His new research with Dr Mariam Fraser, funded through the Wellcome Trust’s Biomedical Ethics Programme, hopes to look in depth at what Professor Rose calls the “micro areas of reasoning and practice” that determine the actions of both research scientists and clinicians in the field of mental health.

“Social scientists,” says Professor Rose, “have been traditionally rather bad at looking at psychiatry and pharmaceuticals. The tendency is to ignore all the science and say, ‘Well, we can see there are vested interests at stake here in the drug companies.’ Or to look to the past and say, ‘It’s eugenics again.’ Or recycle all those explanations we have always had in the social sciences about ‘nasty biological interventions’ versus ‘humanistic psychological interventions’. But actually we need to go beyond that. You can’t treat the science as if it’s in some sort of box. If you really want to understand the social and ethical implications of new technologies in brain research, you have to look at the science, to acknowledge that something new and complicated is going on. The science is part of the social picture - the social implications are deeply embedded in the kinds of calculations researchers and clinicians have to make all the time in their work.”

Professor Rose perceives a fundamental shift in the way science understands mental health. “Psychiatric problems are no longer understood in terms of the social environment, or the family, or even in a psychological space. Everything is now somehow ‘passed through’ the brain and its chemistry. So family matters affect your mental health by affecting your brain and drug addiction affects your mental health by affecting your brain. Yet it really wasn’t that long ago that the idea that you could explain something as fundamental as human feelings in terms of the quanta of a particular chemical in a synapse in the brain would have been deemed absurd. With this research we want to try and understand exactly how this new ‘biomedical model’ of mental health came into existence.”

Phase one of the research is a 12-month historical study, using archives, literature searches and interviews to build up an understanding of the professional, social, political and commercial transformations in the mental health system that enabled the biomedical model to take off.

The study will focus on two particular technologies that have had dramatic impacts on psychiatry: psychopharmacology and genetic research. Psychopharmacology could be said to have ‘begun’ in 1953, with the discovery of chlorpromazine and its subsequent use in US mental hospitals. At that time, says Professor Rose, “Drugs were produced, found to have clinical effects, and then investigated to see what effects they were having on the brain. It was then that theories about defects in certain brain systems, particularly neurotransmitter systems, first began to be formulated. The two key ones were the dopamine hypothesis in relation to schizophrenia, and the monoamine theory in relation to depression. This was really the beginning of what we now call biological psychiatry.”

The advances in understanding of brain chemistry triggered by these early pharmacological treatments have led to the creation of new generations of more targeted, ‘smart’ psychiatric drugs, aimed at specific brain systems - notably the serotonin and noradrenaline systems - at a precise, molecular level. The best known example is Prozac, one of a number of selective serotonin-reuptake inhibitors (SSRIs) introduced in the 1990s.

“For the early drugs,” adds Professor Rose, “the brain biochemistry was secondary to the clinical discoveries. Now the biochemistry is being used as the basis for fabricating the new drugs. These are so-called ‘clean’ drugs, aimed at specific brain systems, and they are now a major motivator of the pharmaceutical industry.”

Genetic research, the other key determinant of the new psychiatry, reflects the fact that psychiatric conditions can run in families. “It’s argued that the genetic basis of these familial traits is in specific variations in genes controlling the neurotransmitters. So, for example, in the inheritance of schizophrenia or manic depression, what one is seeing is a number of genes whose modes of action are on the dopamine system.”

Both psychopharmacology and behavioural genetic research produce strictly biological explanations of psychiatric symptoms or conditions, and also organise their interventions in terms of brain biology. For Professor Rose, “This represents a fundamental shift in how we are thinking not just about psychiatric pathology, but about normal variations in human behaviour as well. It’s very interesting to note that in the early days these biological explanations went hand-in-hand with psychoanalytic explanations. Nate Kline for example, one of the big figures in the early development of psychopharmacology, used a psychoanalytical language to explain the effects of the new drugs in terms of the ‘binding of libidinal energy’. One sees now the gradual effacing of psychological explanations - or at least their shift into cognitive therapies, which are about teaching people the management of their condition.”

Phases two and three of the research are in early planning stages. The intention is to do an ethnographic study, perhaps retrospectively, of the research, testing and marketing of one new compound working on the serotonergic system. Phase three hopes to use fieldwork to look at the impact of new psychiatric explanations and treatments on clinical practice.

Professor Rose sees a real need to bring ethical research down to empirical specifics. “Most of the emphasis in bioethics has actually been on morality, not ethics. It’s been about setting up broad scale committees discussing issues such as informed consent or doing no harm and trying to regulate the field in terms of these broad principles. I’m not sure how much purchase these kinds of deliberations have on day-to-day scientific development - the decisions being made by the researchers, by the pharmaceutical companies, by the clinicians. The science is moving so fast that the moral deliberations are outpaced, and have no bearing on what I call the true ethical dimension, which is the everyday practical decisions involved in science or product development or marketing. We want to look at these empirical questions, right at the point where they are actually being worked out.”

As well as the work on psychiatry, Professor Rose’s department at Goldsmiths has also received two grants for research in the social and ethical impacts of genetics and pharmacogenetics. Carlos Novas is using discourse analysis techniques to look at genetic testing for Huntington’s disease, in particular how genetic counsellors understand their role, and how the ‘risks’ posed by genes are understood by them and by the individual concerned.

As genomic technology is applied in the pharmaceutical industry, increasing resources are being devoted to predictive testing, risk profiling and preventive drugs. Oonagh Corrigan is looking at the issue of genetic risk and its perception among different groups, as well as its impact on the design of clinical trials.

Underpinning all these projects is a desire to have a practical impact. “The hope,” says Professor Rose, “is that in addressing these developments, from a social science perspective but at a detailed and empirical level, we illuminate in a new way the issues that must be addressed by those wishing to regulate these matters - whether that is by legal mechanisms, professional self-regulation or ethical guidelines.”

See also

• Biomedical ethics research projects funded by the Trust: Genetics research awards. Research summaries detailing the work of Professor Nikolas Rose including the projects of Carlos Novas and Oonagh Corrigan

External links

• Sociology at Goldsmiths College London

Further reading

Novas C, Rose N (2000). Genetic risk and the birth of the somatic individual. Economy and Society, special issue on configurations of risk. 29(4): 484-513.

Rose N (1996). Inventing Our Selves: Psychology, power and personhood. New York, Cambridge University Press.

Rose N (1999). Powers of Freedom: Reframing political thought. Cambridge, Cambridge University Press.

Rose N (1999). Governing the Soul: The shaping of the private self. Second edition, London, Free Associations Books.

Rose N (1998). Governing Risky Individuals: The role of psychiatry in new regimes of control. Psychiatry, Psychology and Law. 3(2): 177-196.

Rose N (2000). The biology of culpability: pathological identities in a biological culture. Theoretical Criminology. 4(1): 5-34.

Healy D (1997). The Antidepressant Era. Cambridge, MA: Harvard U P.