Inventing Psychiatric Drug Maintenance

This dissertation explores a major change in the way the maintenance of recovery from mental illness was authoritatively represented between the mid 1950s and the present. A shift from individual case reports to clinical trials as medicines authoritative knowledge-framework made possible a view of mental health as something to be achieved then maintained pharmaceutically. Through a controversial experiment that both produced and studied responders to maintenance drugs, it became possible to assess maintenance drugs in terms of an idealized, optimized state, rather than in relation to a personalized baseline. This new, idealized understanding of mental health emerged in the early 1970s and operated alongside traditional concepts of psychiatric diagnosis and prognosis, where each disease category implied an expected trajectory that interventions could only temporarily alter, for example by sedating or restraining. It harmonized with a managerial style of thinking among mental hospital psychiatrists who imagined a future in which medicated inmates would flow and circulate through institutions, achieving live release, rather than sedimenting into long-term custodial care.

Pharmaceutically-maintained mental health unfolded in treatment phases, in the margins of epidemiological diagrams, in the minds eye of life insurance company medical directors as financial payouts due to suicide, in the pages of medical journals devoted to narrative medicine and in the decisions of physicians considering self-reporting to medical regulators. Mental health achieved and maintained with drugs, viewed from the perspective of business or occupational risk managers was seen as inherently untrustworthy, fragile, and at risk of failing. The result was on the one hand, a medical discourse that confidently represented and even promoted the idea that mental health could be pharmacologically maintained, and on the other a discourse of corporate risk management that saw fragility and risk among anyone who used mind altering drugs. Diverging from studies that isolate specific categories of mental illness, the dissertation bridges histories of pharmacology, medical epistemology, insurance, and professionalization. It shows how a science of maintenance psychiatric drugs evolved to favor the interests of its makers, while at the same time stacking the odds against the very consumers it claimed to serve.