Chapter 3 of Robert Whitaker’s book, Anatomy of an Epidemic, is fairly short and begins his discussion of the history of psychopharmacology and the changes it brought to the practice of psychiatry. Much of this section seems to revolve around the concept of the “magic bullet.”
Mr. Whitaker begins his chapter by recounting the discovery of early antibiotics and the realization that medications could be created that had more toxicity some cells and less for others. He quotes Ehrlich with what I assume will be his definition of a “magic bullet”:
“If we picture an organism as infected by a certain species of bacterium, it will be easy to effect a cure if substances have been discovered which have a specific affinity for these bacteria and act on these alone. (If) they possess no affinity for the normal constituents of the body, such substances would then be magic bullets.”
Now, what are we to make of this idea? We need to see if Mr. Whitaker believes that magic bullets exist as described by Ehrlich or if he harbors some doubt. We may be able to poll people and quote those who are “true believers” in such things, but is there any factual evidence that these exist in any area of human experience?
Mr. Whitaker cites salvarsan as the first “magic bullet.” How does it stack up? It is an organic derivative of arsenic that was able to kill the organism causing syphilis. So far, so good. But did it really have “no affinity for the normal constituents of the body?” Not really, salvarsan had significant toxicity that worsened on exposure to air. The Merck Index simply says, “It is poisonous!” It is no longer used therapeutically. It does not seem to be much of a “magic bullet” though it was indeed an advance for its time. The next “magic bullet” mentioned is sulfanilamide, a member of the class of medications called the sulfonamides, which found it usefulness in treating bacterial infections. It also worked well to kill bacteria, but the sulfonamides are also known to cause kidney damage, anemias, hypersensitivity reactions, hepatitis, hypothyroidism, arthritis, and various neuropsychiatric disturbances (Goodman and Gilman’s The Pharmacological Basis of Therapeutics). These are not all common side effects, but they show that this medication does have effects on the “normal constituents of the body.” The third “magic bullet” mentioned is penicillin. This comes closest to the idea of a “magic bullet” due to its usefulness in treating infections, but even it is not without potentially harmful effects on the body (most frequently allergic reactions). Mr. Whitaker points out that as more and more medications were synthesized, society became more optimistic about conquering more and more types of diseases. The “magic bullet” was about to change psychiatry.
But have we ever found any medication that meets Ehrlich’s definition of a “magic bullet?” Do any of Mr. Whitaker’s examples suffice? It is telling that Mr. Whitaker uses examples of antibiotics for his “magic bullets.” If there were ever to be one discovered, it would be among the medications that target non-animals (even better — noneukaryotes, i.e. bacteria) that affect animals (eukaryotes). This is Mr. Whitaker’s best chance, but he cannot find a medication without some risk to the host. How, then, are we to understand the idea of the “magic bullet?” It is not a real thing — it is an ideal. We do not criticize a drug for not being a “magic bullet,” but we can assess how close it comes to this ideal.
As Mr. Whitaker tracks drug development into the field of psychiatry, he notes the progress of mental health treatment through the “moral therapy” era and into an era of “physical treatments.” Contrary to Mr. Whitaker’s statement on page 43, moral therapy was not viewed as a “failed form of care” but became impractical and financially unsupported, leading treaters to seek new forms of care that fit with the cultural forces of the time. Still, Mr. Whitaker notes several forms of treatment that range from the head-scratchingly bizarre (tooth extraction) to inexplicably successful (electroconvulsive therapy). He also notes the shortsighted foray into the frontal lobotomy. His description of the state of some mental hospitals of the time is well-designed to elicit sympathy and horror. Against this backdrop, Mr. Whitaker quotes various influential people expressing the great need for mental health care and with great hopes for psychiatric treatments. His last quote is from Dr. Howard Rusk who said, “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. They are all medical problems requiring medical care.” With this, Mr. Whitaker sets up the argument that he intends to knock down.
So, why is this chapter in the book? What purpose does is serve in Mr. Whitaker’s argument? It seems to do a few things such as
1. Set up the idea of the “magic bullet” as a tool with which to criticize psychiatric medications;
2. Show that historically psychiatrists have provided treatments that over time have been repudiated; and
3. Blur the lines between opinion and fact.
The first point is rhetorically useful, but intellectually problematic. If you want to convince people that something is flawed, it is often better to compare your subject to a very high standard. This makes it stand out more in stark contrast. A more nuanced and realistic approach may not be nearly as motivating to your audience once they realize that the flaws you are pointing out are not unique. Such is the case with the “magic bullet.” No matter where you get your treatment or what kind of treatment you get, there will always be risks of side effects. There is no treatment that ONLY treats what you aim it at and has no other effects on the person.
The second point is valid and is a sober reminder of the need for responsibility in ALL fields of medicine. The point is not unique to psychiatry. The emotional content of the section dealing with this point, however, is apt to be misused to discredit psychiatrists in particular.
The third point may or may not be widely accepted, but here is why I think it plays a role in this chapter. Almost all of the quotes that Mr. Whitaker uses in the later part of this chapter are OPINIONS. As opinions, I may choose to agree with them or not, with no harm to logic or meaning. If I read the last part of this chapter as opinion, then the chapter winds up saying something like, “Infectious disease doctors have cool drugs, and some people hope that psychiatry gets drugs that rival the ideal qualities of antibiotics, though they may not.” If I read the same section as fact, however, then I wind up believing that “infectious disease doctors have cool medications, and successful psychiatric medications will have the same ideal qualities as the antibiotics.” It’s not much of a difference, but being disappointed in the opinion reading is less motivating and attention-getting than feeling lied to with regard to the fact reading.