It is with great skill that Bergner places Caroline’s story in context of the history of modern psychiatry. It’s hard to do justice to the sweep of the larger story he tells, but probably the most shocking part is the utter randomness that has characterized so much of the modern search for psycho-pharmaceuticals, combined with the utterly devastating side effects they can have. Bergner tracks the history of treatments like lithium, S.S.R.I.s and antipsychotics. In many cases, researchers only stumbled across the drugs’ potential to ameliorate symptoms. Of lithium, he writes that 19th-century doctors used it to treat kidney stones. Later it was among the ingredients in 7-Up. Even though lithium was approved by the F.D.A. for psychiatric use in 1970, “no one had more than a vague concept of how the drug worked neurologically,” Bergner notes, and they still don’t.
Bergner interviews a group of researchers who, despite the accidental origins of numerous pharmaceuticals, strive today to develop them into substances that will truly improve people’s lives. This is an interesting set of interviewees, all dedicated, hardworking, highly knowledgeable scientists, who frankly acknowledge how poor the efficacy of many drugs is, how much of a toll they can take on people who use them and how little we know about how the brain actually works.
Bergner’s subjects, as well as the scientists and clinicians he interviews, also attest to the fuzziness of many diagnostic and behavioral boundaries. Standard diagnoses often collapse what some scientists believe are different conditions into one, whereas other diagnoses wall off conditions that are perhaps not so different at all. It’s possible that psychosis, for example, is not really one disorder but dozens of them.
Where the history of drug development has been astonishingly haphazard, and our grasp of brain function is disturbingly low-level, the history of psycho-pharmaceutical marketing has been clever and effective. I still recall when an undergraduate friend confidently told me that her recent bout with depression had resulted from a chemical imbalance in her brain. I was dazzled by the explanation. It made her sadness cleaner, more easily resolved, less unglamorous.
It turns out that we had both signed on to the “chemical imbalance theory,” which proposed, in the 1960s, that depression could result from a deficiency of neurotransmitters. This ultimately evolved into the idea that too many or too few neurochemicals could cause different kinds of mental illness, such as psychosis. Biology became ascendant in our understanding of psychiatric conditions, which led to a vision of medicalized mental health that one of Bergner’s scientists calls “a house of cards.” The idea that S.S.R.I.s, for example, could further our understanding of disorders, the scientist observed, was like saying, “I have pain so I must have an aspirin deficiency.”