The story of Dr. Faust is a familiar one to me. I was (academically) under the thrall of the terrible deals the devil seemed to routinely get buyers to agree to during my time at Amherst. I scored a production of Stein’s post-modern take—Dr. Faustus Lights the Lights—in my 2nd year. In my junior year, I built an independent study course on hell and the devil. I related to the ambition of Dr. Faust. The valuation of his immortal soul was low, but only from his perspective—honestly, it is unclear if he believed he was selling anything.
I have been a long-time fan of the various Faust myths. The real story, to me, is how often we sell our souls for so much less.
Psychopharmacology, as a field of medical practice, I believe to be in this category. It was oversold to me in my medical training and to the public for a powerful reason: it was the road to riches. Psychopharmacology is a great way to sell psychiatric medication.
The person who started the brand of psychopharmacology was himself a psychiatrist. You've heard the name before. We've all heard the name by now. It was Arthur Sackler. Arthur Sackler was the scion of the Sackler family, which went on to produce the opioid crisis via its controlling interest in Purdue Pharmaceuticals. Sackler was a psychiatrist when psychiatry learned it could change the brain and the mind through biology. The early breakthroughs in psychiatric medicine were all interventional: among them, the lobotomy and the malarial cure for insanity--both of which won Nobel Prizes in medicine.
Arthur Sackler was a psychiatrist in a family of brothers who were psychiatrists. His sons, notably Richard, learned the lesson—it’s all about marketing—and used this playbook for marketing to murderous effect at Perdue Pharma with Oxycodone. He realized early on intervention was not the road to big returns; well-marketed drugs were. This meant well-designed package inserts from the FDA with the right indications, warnings, and language to allow the advertising and drug reps to SELL hard.
Sackler worked his way through medical school by writing ad copy for psychoactive drugs. He went on to buy the agency he worked for and a controlling interest in his only competitor in the field. Sackler’s pivotal ah-ha was this: to sell drugs, you had to sell psychiatrists the idea they should be prescribing drugs. Sackler was a great psychiatrist—about the mindset of other doctors. What he sold psychiatrists was a brand-new career. No longer would they be spending time listening; they could spend much less time- and make a lot more money-- by just prescribing. It was science. We were experts.
Since Arthur Sackler, the psychiatrist, knew what made psychiatrists tick, he knew they had to feel good about this new career. Science is reassuring for physicians. The more we think about science, the less we have to sit and feel uncomfortable with human suffering and crying in our office.
Psychoanalysts did a lot of sitting. Psychoanalysts did a lot of listening. Psychoanalysts did not do a lot of high-volume prescribing. And this is a problem if you're in the drug-marketing game. Sackler saw it would not do. Physicians had to be convinced that being a psychoanalyst was a loser of a gig. And they needed a new, more scientific identity. Arthur Sackler would provide that identity. They would be psychopharmacologists!
The early breakthroughs in psychiatric medicine were all interventional: the lobotomy, for instance, and the malarial cure for insanity (both of which won Nobel Prizes |!) Now, they would be pharmacological! Lobotomy was a one-trick pony from a merchandising perspective. Pills were the gift that would go on giving.
Pharmacology is a word we remember from medical school. Psychopharmacology puts two words together in an appealing way. It's easy to go from being a psychiatrist to a psychopharmacologist--you'll be prescribing medicine! For surgeons, subspecialty names spell it out. Neurosurgeons? Surgeons that cut your brain. Or maybe your spine. They're doing some cutting. Internal medicine doctors prescribe medicine for the inside of you. Psychiatry is clearly about psychiatric problems. But it doesn't build the brand for prescribing medicine into their nomenclature. This would need to be fixed.
Marketing executives like Sackler know branding. Psychopharmacology was a brand that could win. This meant creating an entire lexicon to appeal to both regulators and physicians. You need to talk about neurotransmitters! This is where the psychopharmacology happens!!
As a practical matter, most neurotransmission is accomplished by crucial--but potentially volatile --glutamate and glycine. Fussing with these can lead to seizures. Seizures are bad for business. The focus must be on regulatory neurotransmission. So, neurotransmission became the sales pitch.
It gives us doctors something to occupy our minds while we prescribe oral medication people can take at home or forget to take at home. It doesn't matter in dollars and cents as long as the medicines are prescribed.
For a drug company to make money, someone needs to prescribe a drug, someone needs to pick the drug up at the pharmacy, and they need to keep picking the drug up at the pharmacy. There needs to be a way for all of these things to be paid for. Doctors need to be convinced to participate in the system. They need to be made to focus on small molecules that can get into your brain and change neurotransmission but not kill you. Arthur Sackler thought neurotransmission would be a winner, and he wasn't wrong. Sackler and Big Pharma made billions. Soon, even psychopharmacologists became too fancy to drive large-scale sales, and doctors were replaced by “behavioral health prescribers.”
This new focus turned out to be a tragic waste for patients and families. The truth is these drugs don't do much-- not enough to be worth the trials and errors, the side effects, the deaths. A counter-revolution is brewing. Ironically, the birth of this revolution was partly midwifed by the same Arthur Sackler. As an early ECT doctor and author of papers on psychedelic medicine, he knew interventional care worked! It wasn’t SELLABLE at the time, so he sold legal drugs instead.
We are told we have a mental health crisis. This is another lie. We do have a suffering crisis. And that suffering crisis has been created partly by our overutilization of interventions that don't do much. It would be as if we had a mobility crisis because we spent decades selling water instead of gasoline, and cars weren't going anywhere because we were filling in with something that could not be expected to make them move.
Our mental health crisis is an ineffective psychopharmacology crisis. We were sold away from thinking about suffering. And we bought it. We are buying it to this day. And we need to stop buying it. Big Pharma has a good sales pitch, but its medications are not good enough. As physicians, patients, and families, and I've been all three, we need to get vastly more serious about what we should be doing, which means being serious about what we did. And what did we do with all those pills? With all that psychopharmacology? It wasn't much.
There is genuine hope, however. That hope is here now. I have seen a bright light of hope through my work as an interventional brain medicine physician; I have seen depression end with the treatment of the brain directly. The Observational AI revolution is here, and innovations guided by AI are changing what is possible.
We have entered a new world of mental health. This book tells how we got here and where we are going. It will inform and educate and will even lead some readers who may be suffering from mental health issues to durable remission of their symptoms. Depression and other psychiatric disorders can be put into remission TODAY--- in as little as five days, quickly and safely. I’ll preview that future for my readers because, as it happens, I am not just the author of this substack but also a psychiatrist. I am a research scientist and, most importantly, a patient who’s experienced many of these treatments myself. I’ve been part of the failure and part of the revolution.
Owen, if psychopharmacology were a Disney character, which would it be?