The current issue of Culture, Medicine, and Psychiatry is largely a special issue devoted to the topic of humanness and modern psychotropy. As per the introduction, “Anthropological Engagements with Modern Psychotropy,” by Michael Oldani, Stefan Ecks, and Soumita Basu:
The conception of this special issue was partly inspired by an idea of “modern psychotropy” formulated by the historian, Smail (2008; see also Campbell et al. this volume). We borrowed this concept in order to expand the linkages, the multiple efficacies of, and the range of anthropological perspectives triggered by these compounds. Smail’s On Deep History and the Brain argues that historical changes over the millennia were also changes of brain–body interactions. Anthropologists still work with a Boasian notion of a psychic unity of humankind, that places only culture in history but not the brain. Neurohistories, such as Smail’s, troubles this assumption. And, given how deeply psychotropics have seeped in, it seems time for anthropologists to reconsider this position. Whether interpreted as medicinal, pathological, and/or addictive, psychotropics can now be obtained il/legally and have become another everyday “set of tools” (Rouse) for human being to modify or enhance their mood, emotional states, behavior, and social relations.
The contributions to this special issue, either directly or indirectly, are pointing our attention to particular saturation points of modern psychotropy, points that require further anthropological elaboration and critique. Addicts in recovery (Meyers), (pre)Alzheimer’s patients (Leibing), single women and the rural poor in India (Pinto and Ecks, respectively), and the worried well in the U.S. (Oldani) share polypharmaceutical lifestyles and futures determined in large part by overprescribing, overuse, and overreliance of psychotropics. In the United States, still the epicenter of psychotropic science, marketing, and ab/use, clusters of strong resistance have emerged.
Along with this introduction and a forward by Benjamin Campbell, entitled “On Deep History and Psychotropy,” which articulates a series of anthropological questions and concerns that arise from Smail’s work, the issue comprises five articles and a concluding commentary, “Cultural Scripts: The Elusive Role of Psychotropic Drugs in Treatment,” by Carolyn M. Rouse.
The problem of lying as a feature of medication compliance has been well documented in anthropological and clinical literatures. Yet the role of the lie—its destabilizing effects on the continuity of drug treatment and therapy, as a technology of drug misuse, or as a way to understand the neuro-chemical processes of treatment (pharmacotherapy “tricking” or lying to the brain)—has been less considered, particularly in the context of opioid replacement therapy. The following paper is set against the backdrop of a three-year study of adolescents receiving a relatively new drug (buprenorphine) for the treatment of opiate dependency inside and outside of highly monitored treatment environments in the United States. Lies give order not only to the experience of addiction but also to the experience of therapy as well. In order to better understand this ordering of experience, the paper puts the widely discussed conceptual duality of the pharmakon (healing and poison) in conversation with a perilously overlooked subject in the critical study of pharmacotherapy, namely the pharmakos or the personification of sacrifice. The paper demonstrates how the patient-subject comes to represent therapeutic promise by allowing for the possibility of (and often performing) deceit.
“We Always Live in Fear”: Antidepressant Prescriptions by Unlicensed Doctors in India
Stefan Ecks and Soumita Basu
In India, psychopharmaceuticals have seeped deep into both formal and informal pharmaceutical markets, and unlicensed “quack” doctors have become ready prescribers of psychotropics. These ethnographic insights trouble policies that aim at closing the treatment gap for psychiatric medications by “task shifting” to low-skilled health workers as if medications were exclusively available by prescription from public sector psychiatrists. This article describes what these doctors, known as rural medical practitioners (RMPs), know about psychotropics and how they use them in everyday practice. Unlicensed doctors learn about psychopharmaceuticals through exchanges with licensed doctors, through visits by drug companies’ sales representatives, and through prescriptions brought by patients. Although the RMPs exist outside the margins of legitimacy, they are constrained by a web of relations with patients, licensed doctors, pharmacists, drug wholesalers, and government agents. The RMPs do not only prescribe but also dispense, which leads to conflicts with licensed medicine sellers. They “always live in fear” both because they are illegal prescribers and because they are illegal sellers of medications. The article shows that any form of strategic ignorance among policy makers about the local importance of informal practitioners in India can only lead to lopsided interventions.
Although the risk factors, biomarkers, and medications for Alzheimer’s disease appear to be almost identical in 1993 and 2013, profound changes can de detected throughout this time period. This article maps these recent changes in the conceptualization of Alzheimer’s disease, especially the emerging trend toward prevention. While some preventive practices (e.g., brain training) and the search for early signs and biomarkers (such as APOEε4) have existed for a long time, the recent broadening of scope to include cardiovascular risk factors and their prevention, paired with pre-symptomatic detection of disease-specific biomarkers, has considerably impacted the conventional understanding of this syndrome and the possibilities for pharmacological and non-pharmacological interventions. The rationale for emphasizing multiple logics when explaining these changes is to avoid simplified argumentative pathways that exist among some scientists.
A cultural imaginary identified as “fashion” links single women with problems of desire in contemporary India, setting the stakes not only for independent living, but also for the ways distresses may be read and treated. From celebrity cases to films to clinical practices oriented around pharmaceuticals, the mechanisms of this imaginary locate female personhood at a series of critical junctures or “hinges,” from pharmaceuticals to drugs of vice, from desire to expressions of disorder, and from singularity or independence to destitution. In each of these turns, as psychiatrists read female bodies for signs of affliction and media portray counter trajectories of aspiration and downfall, certain realities are shielded from consideration, including sexual violence in intimate settings.
Psychiatric medication, or psychotropics, are increasingly prescribed for people of all ages by both psychiatry and primary care doctors for a multitude of mental health and/or behavioral disorders, creating a sharp rise in polypharmacy (i.e., multiple medications). This paper explores the clinical reality of modern psychotropy at the level of the prescribing doctor and clinical exchanges with patients. Part I, Geographies of High Prescribing, documents the types of factors (pharmaceutical-promotional, historical, cultural, etc.) that can shape specific psychotropic landscapes. Ethnographic attention is focused on high prescribing in Japan in the 1990s and more recently in the Upper Peninsula of Michigan, in the US. These examples help to identify factors that have converged over time to produce specific kinds of branded psychotropic profiles in specific locales. Part II, Pharmaceutical Detox, explores a new kind of clinical work being carried out by pharmaceutically conscious doctors, which reduces the number of medications being prescribed to patients while re-diagnosing their mental illnesses. A high-prescribing psychiatrist in southeast Wisconsin is highlighted to illustrate a kind of med-checking taking place at the level of individual patients. These various examples and cases call for a renewed emphasis by anthropology to critically examine the “total efficacies” of modern pharmaceuticals and to continue to disaggregate mental illness categories in the Boasian tradition. This type of detox will require a holistic approach, incorporating emergent fields such as neuroanthropology and other kinds of creative collaborations.
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