A Psychotropical Paradise

By THOMAS MEANEY
The Wall Street Journal
June 24, 2006; Page P12
Artificial Happiness By Ronald W. Dworkin
Carroll & Graf, 336 pages, $24.95

If the pursuit of happiness was once an ideal in American life, the entitlement to happiness may now have replaced it. Since the late 1980s, when psychotropic drugs first came on the market, grateful Americans have been lining up at the counter.

Prozac, Zoloft, Paxil, Wellbutrin and a host of other antidepressants have been embraced as practical solutions to everyday unhappiness. More than 15% of Americans now use one of the above. Needless to say, they are not all clinically depressed. Whereas Sigmund Freud once described the goal of psychotherapy as "transforming hysterical misery into ordinary unhappiness," many doctors now see it as their duty to eradicate ordinary unhappiness completely.

Ronald W. Dworkin's "Artificial Happiness" is a fierce indictment of this wishful thinking. An anesthesiologist with a doctorate in political philosophy, he is in a rare position to offer a serious critique of the medical establishment and its influence on American culture. Rather than simply deploring the over-prescription of antidepressants, Dr. Dworkin tells the story of a fascinating turf war among doctors, psychiatrists and members of the clergy over the fate of the American brain. More generally, "Artificial Happiness" examines the implications of a new class of "artificially happy people" and raises important questions about the function of doctors in a democracy.

Dr. Dworkin's timeline starts with the rise of specialization among physicians in the 20th century. Whereas father-confessor-type general practitioners once prevailed in the U.S., nearly 80% of them had specialized by the 1970s. Specialization led to major advances in medical technology, but it also encouraged doctors to prize scientific expertise over personal care, accelerating a trend that had begun as long ago as the 1920s. Social difficulties were turned over to social workers and emotional problems to psychiatrists, and ethical dilemmas became the domain of bio-ethicists.

But specialization had its breaking point. Primary-care doctors came under fire for ignoring certain everyday health problems—depression first among them. Under public pressure, these physicians looked for ways to address the problem scientifically. Not unlike the medieval doctors who blamed melancholy on black bile in the spleen, primary-care doctors discovered the source of depression in the brain's neurotransmitters. They could tame these neurotransmitters with minor tranquilizers and later more effectively with antidepressants. When properly prescribed, the new drugs worked dazzlingly well—so well, in fact, that doctors began prescribing antidepressants for less definitive forms of depression. Soon many patients and doctors alike were conflating everyday unhappiness with the genuine disease of depression.

Enter the psychiatrists, who naturally resented primary-care doctors for treading on their responsibility for managing mental well-being. The main charge they leveled at the doctors was over-prescribing drugs they did not know how to use. Psychiatrists determined levels of depression in their patients through a series of rigorous inventories and used psychotropic drugs as a complement to their therapy, not as a mainstay. Meanwhile, primary-care doctors were prescribing antidepressants for every shade of sadness. "By liberally prescribing psychotropic drugs," writes Dr. Dworkin, "doctors actually dodged the whole messy business of defining normal."

According to Dr. Dworkin, the crisis in the "medical practice revolution" came when primary-care doctors appealed to the public for their defense. With psychotropic drugs sales skyrocketing in the 1990s, they had little difficulty enlisting popu