Abstract

This study deals with the foundations of the psychiatric drug epidemic, aiming to analyze the medicalization of subjectivity and the fetishism of psychotropic drugs in their fundamental bases. It is a theorical reflection in the light of discourse analysis inaugurated by Michel Pêcheux, from which it presents a gesture of interpretation, allowing the identification of the psychiatric drug epidemic as an expression of the medicalization of life. Based on the critique of the foundations of the capitalist form of consumption and prescription of psychotropic drugs, this analysis demonstrated how the social metabolism model of capital imposes a fetishized therapy on the subjects. We hope to contribute to the practices of those who fight for the legacy of the anti-asylum movement and thus add to the efforts of the subjects involved in the production of effectively humanized and critical practices.

Keywords:
Subjectivity; Psychotropic Drugs Fetishism; Mental Health; Capitalism

Introduction

The use of psychotropic medications,¹1The range of drugs that, in different ways, affect mood and behavior (Rang; Dale, 2010). or psychotropic drugs, has been increasing dramatically since their introduction to the market in the mid-1950s. In recent years, there has been an even more significant growth in the consumption of these products. In Brazil, according to the 2016 National Survey on Access, Use and Promotion of Rational Use of Medicines in Brazil (PNAUM), which analyzed the 20 pharmacological subgroups most used by primary health care users, antidepressants, antiepileptics, and anxiolytics were among the most consumed medications, surpassed only by non-steroidal anti-inflammatory drugs (NSAIDs), antihypertensives and antidiabetics (Álvares et al., 2017ÁLVARES, J. et al. Pesquisa nacional sobre acesso, utilização e promoção do uso racional de medicamentos: métodos. Revista de Saúde Pública, São Paulo, v. 51, n. supl.2, p. 4s, 2017. DOI: 10.11606/S1518-8787.2017051007027
https://doi.org/10.11606/S1518-8787.2017... ).

As a result of the social implications of the COVID-19 pandemic, this trend of medication use has intensified even further, so that, according to the survey carried out by the IQVIA consultancy,²2The aforementioned acronym arises from the formulation derived from the association of the companies Quintiles and IMS Health and the term “via,” from the Latin, which means “through.” The merger took place in 2006 and is a company focused on information and clinical research services and technological solutions. at the request of the Conselho Federal de Farmácia (CFF - Federal Pharmacy Council), it was found that in the first half of 2020, compared to the same period in 2019, there was an increase of almost 14% in sales of antidepressants and mood stabilizers. The number of units sold jumped from 56.3 million in 2019 to 64.1 million in 2020 (Venda…, 2020VENDA de medicamentos psiquiátricos cresce na pandemia. IQVIA - Quintiles & IMS Health e VIA, Teresina, 10 set. 2020. Disponível em: <Disponível em: https://cff.org.br/noticia.php?id=6015#:~:text=Levantamento%20feito%20pela%20consultoria%20IQVIA%20a%20pedido%20d >. Acesso em: 23 nov. 2021.
https://cff.org.br/noticia.php?id=6015#:... ).

The worldwide profile of increasing consumption of psychotropic drugs has worried a number of researchers and organizations in recent years, to the point where, according to Whitaker (2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.), it has become a psychiatric drug epidemic. This article starts from the thesis that, in reality, the way capitalist society deals with the use of psychotropic medications is epidemic.

We share the notion proposed by Szasz (1980SZASZ, T. S. Ideologia e doença mental: ensaios sobre a desumanização psiquiátrica do homem. 2. ed. Rio de Janeiro: Zahar, 1980.), who considers that mental illness/disorder is a form of myth, of ideology. This notion does not deny the existence of different forms of psychic distress, nor does it oppose the idea that the number of subjects with such problems is increasing and reconfiguring itself in recent decades, it simply rejects the reductionism of equating psychic distress with the restricted parameters of organic diseases.

Thus, the psychiatric drug epidemic is very particular, as it is structured on the iatrogenic process, which founds the so-called scientific psychiatry: the conception that forms of psychic suffering have a biological cause, structured in a supposed alteration of a normal neurochemical pattern. It was as a result of this conception that the biomedical discourse’s capture of human subjectivity and forms of psychic distress became possible. This fact reconfigured all psychiatric and psychological therapy, causing the production of a monumental number of subjects in suffering and with organic problems induced by the use of these drugs (Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.).

For more than 40 years now, some research has dismantled, in positivist terms, the biologicist hypotheses of the causes of so-called mental disorders, as pointed out by reviews by Whitaker (2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.) and Coser (2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010.). In this sense, the criticisms made by Peter Lehmann and Salam Gómez (2018LEHMANN, P; GÓMEZ, S. (Ed.). Dejando los medicamentos psiquiatricos: estrategias y vivencias para la retirada exitosa de antipsicóticos, antidepresivos, estabilizadores del ánimo, psicoestimulantes y tranquilizantes. Berlin: Peter Lehmann Editorial, 2018.), Marcia Angell (2014ANGELL, M. A verdade sobre os laboratórios farmacêuticos: como somos enganados e o que podemos fazer a respeito. Rio de Janeiro: Record, 2014.), in addition to Robert Whitaker himself (²⁰¹⁷WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.) stand out worldwide; and, in Brazil, professors Fernando Freitas and Paulo Amarante (2017FREITAS, F.; AMARANTE, P. Medicalização em psiquiatria. 2. ed. Rio de Janeiro: Editora Fiocruz , 2017.) also contribute significantly to the analysis of this phenomenon. All of these authors point, to a certain extent, to the economic and political determinations exercised, especially by the pharmaceutical industry and sectors of the modern State, as a fact that conditions the creation and maintenance of the psychiatric drug epidemic.

Starting from these assumptions, we seek in the theoretical-analytical devices of discourse analysis the necessary anchoring for taking a position in the game of meanings materialized in medicalized subjectivity. To this end, it is worth pointing out that the French philosopher Michel Pêcheux (2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014.) sought to formulate a materialist theory of semantic processes based on historical materialism, linguistics, and psychoanalysis, as three regions of knowledge, which is the nodal point that theoretically articulates the proposal of this reflection. Therefore, this article does not aim to recount what was said by this segment of mental health criticism, but to analyze the medicalization of subjectivity and the fetishism of psychotropic drugs in their fundamental bases in the light of Marxian criticism, and thus contribute with another possibility of reading the issue, from a discursive perspective based on Michel Pêcheux.

The psychiatric drug epidemic as an expression of the medicalization of life

The consumption of psychiatric drugs, to be thought of as an epidemic, is only possible due to an even broader, perennial, and ideologically legitimized phenomenon by capitalist society: the medicalization of life. According to Freitas and Amarante (2017FREITAS, F.; AMARANTE, P. Medicalização em psiquiatria. 2. ed. Rio de Janeiro: Editora Fiocruz , 2017.), medicalizing is not limited to taking care of oneself with medication. In general, the medicalization of life is configured as a process of “[…] transforming experiences considered undesirable or disturbing into health objects, allowing the transposition of what is originally from the moral or political social order to the domains of the medical order and related practices” (Freitas; Amarante, 2017FREITAS, F.; AMARANTE, P. Medicalização em psiquiatria. 2. ed. Rio de Janeiro: Editora Fiocruz , 2017., p. 14; our translation). However, the process of medicalization is inseparable from the constitution of modern medicine, and its understanding requires a historical analysis of the reconfiguration of the doctor’s place, as determined by capitalist society since the 18th century.

From this perspective, the development of productive forces and biologicist positivism allowed us to understand the physiological bases of bodily functioning, providing more effective medical treatments for some diseases of the time. In this way, medicine, now with a scientific basis, claimed authority over illness and its issues, becoming the spokesperson³3From a discursive perspective, the position of the spokesperson consists of one who is “at once as a visible actor and an eyewitness to the event […]” (Pêcheux, 1990, p. 17; our translation). It is configured, first of all, as a subject who speaks “in the name of…”, through a visual effect “[…] which determines this conversion of the gaze through which the invisible of the event finally allows itself to be seen: the spokesperson exposes themselves to the gaze of the power they affront, speaking in the name of those they represent and under their gaze” (Pêcheux, 1990, p. 17; our translation). for bourgeois science in relation to health issues (Frances, 2013FRANCES, A. Saving normal: an insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. New York: William Morrow, 2013.). In this sense, Freitas and Amarante (2017FREITAS, F.; AMARANTE, P. Medicalização em psiquiatria. 2. ed. Rio de Janeiro: Editora Fiocruz , 2017., p. 22) state that “it is not simply an evolution of scientific knowledge - objective, neutral and free from social interests and conflicts. It is, above all, medical knowledge resulting from processes of social construction of power over individuals” (our translation).

In this way, the problematization of scientificity in psychiatry leads to the analysis of the conditions of scientific knowledge production in capitalism, considering them, to a large extent, as a result of the determinations of the exploitation of capital over medical practice. Starting from the notion of mirroring developed by Lukács (2013LUKÁCS, G. Para uma ontologia do ser social II. São Paulo: Boitempo, 2013.), it is stated that the process of scientific production is a particular form of reflection-the scientific one. This form of mirroring, which becomes knowledge, is a dialectical and contradictory reflection of objective reality systematically apprehended by subjectivity. This systematic apprehension takes the form of a concrete thought based on successive approximations (Marx, 2008MARX, K. Contribuição à crítica da economia política. 2. ed. São Paulo: Expressão Popular, 2008.).

Saying that knowledge production is a dialectical process means that it is historical and that there was no “[…] pre-epistemological ‘stage’ in which ‘men’ confronted the world in a state of complete ignorance […]” (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014., p. 174, emphasis added; our translation). In this way, when producing knowledge-an active, teleologically placed human action-the social being focuses on this objectivity and grasps, through successive approximations and stances, its laws and foundations, in order to continue modifying it based on social needs (whether they are of the human race or of the reproduction of capital).

Understanding, from historical materialism, that the centrality of the process of producing scientific knowledge is objective, one must then consider the fundamental determination of the class struggle in this process, since:

The constitutive nature of the relationship between economic and knowledge production is of the founder-founded type; not in a historiographical way or based on a valuative hierarchy, but under an ontologically dialectical consideration. Lukács (2013LUKÁCS, G. Para uma ontologia do ser social II. São Paulo: Boitempo, 2013., p. 30; our translation) states that “[…] science rises from the thought and praxis of everyday life, primarily from work, and always returns to it, fertilizing it.” In this way, work and science are articulated in reciprocal co-determination, grounding and justifying each other, since “[…] the conditions of the production of scientific knowledge are inscribed in the conditions of the reproduction/transformation of the relations of production […]” (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014., p. 172; our translation). In other words, given the centrality of work in social reproduction, the economic sphere will demand from the science complex forms that are compatible with its (re)production parameters.

It is also worth highlighting that the process of producing broader knowledge, including medical knowledge, arises from the contradictory dynamics of the constitution of theoretical ideologies, which are generally mediations between practical ideologies and knowledge production (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014.), with the essential function of guiding certain meanings, ensuring the operationalization of scientific praxis. Such ideologies appear in the form of scientific ideas, general and particular conceptions of a regional epistemological nature (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014.). As they exist objectively and perform a social function, they are not separated from the history of class struggle.

In this process, the inseparable relationship between economic production and knowledge production is expressed, since, dialectically, practical ideologies, based on everyday life and oriented towards work, assign forms and limits to theoretical ideologies. However, this condition does not nullify the subject’s action in the production of scientific knowledge, it simply places it in its proper place, since “the process of the production of knowledge operates through the taking of positions (‘demarcations’, etc.) for scientific objectivity” (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014., p. 182, emphasis added; our translation). Now, whoever takes a stand for something is not objectivity, but a subject over/under an objectivity. Marx, and later Lukács, remember that the social being is not passive, but rather a being that responds dialectically, according to the objective historical conditions that determine them.

In this way, the process of the production of scientific knowledge “[…] is a ‘continuing break’; it is as such co-extensive with the theoretical ideologies from which it never ceases to separate itself, so that it is absolutely impossible ever to have a pure ‘scientific discourse’ unconnected with any ideology” (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014., p. 182, emphasis added; our translation), which calls into question a supposed neutrality in the field of science.

From an ontological point of view, then, in the case of a socialist system, for example, production would continue in dialectical articulation determining theoretical ideologies, and the function of ideologies would therefore not be restricted to class societies (Lukács, 2013LUKÁCS, G. Para uma ontologia do ser social II. São Paulo: Boitempo, 2013.). From this perspective, despite meeting social demands for care and health care, medicine, like other categories in the sector, is determined and structured dialectically with the social metabolism of its time. The doctor,⁴4In this article, the term “doctor” refers to a historically produced subject position in discourse. in this historical time, is, therefore, the doctor of capitalism, forged under the scientific hegemony of positivism. This model also forms the basis of what is conventionally called real socialism.

One of the consequences of this new social role assumed by the doctor is the redefinition of the patient’s role. Considering the various historical particularities of times and societies, the role of sick person regularly served to stabilize a general notion of norm, determined through their denial of what would be normal, with the sick person being the constitutive margin of this parameter. However, with the advancement of capital society and its economic imperative to reproduce and legitimize itself, the patient’s role began to serve two new and inseparable purposes: entry into the capital valorization circuit and the legitimization of medical power. The patient then began to be produced from a commercial perspective, becoming one of the most profitable businesses today.

The structuring of health services under the global predominance of a curative, clinical, hospital-centered, and pharmacological character has produced a certain type of patient: the consumer patient. From this perspective, the knowledge of medicine, in its biomedical expression, has become the discourse that structures and legitimizes-mainly through its diagnostic and therapeutic manuals-the margin not only of the parameters of normal and pathological, but the fundamental behaviors that must be used on these subjects. In this way, the sick person of this historical time, due to the medical alliance with the maintenance of capitalist logic, is the sick person of capital, (re)produced fundamentally under its laws and logic.

In a way, this restructuring movement, from the perspective of Foucault (2019FOUCAULT, M. A história da loucura na idade clássica. São Paulo: Perspectiva, 2019.), was rehearsed by Philippe Pinel in the movement known as alienism, which took place during the turbulent events of the French Revolution, in which Pinel actively participated. From this context, under the social determinations of the time, a profound transformation began in the foundations of what is known today as a hospital.

Historically, the hospital emerged as a space associated with Christian ideas of welcome and solidarity, as the etymology of the word suggests-in Latin, the word hospital means lodging, hospitality. In the 17th century, however, the hospital began to play a more explicit social function, especially in relation to the role of the madman and madness in Western Europe. This function was the systematic exercise of segregation and isolation of certain social groups, mainly crazy and/or poor people (Foucault, 2019FOUCAULT, M. A história da loucura na idade clássica. São Paulo: Perspectiva, 2019.). In this temporal gap lies alienism, when, on the occasion of the French Revolution, medicine, with the aim of humanizing the General Hospital and making it more consistent with Enlightenment preaching, converts it into a medical institution par excellence (Foucault, 2019FOUCAULT, M. A história da loucura na idade clássica. São Paulo: Perspectiva, 2019.). In this sense, the hospital gradually became secondary to the ideals of charity and segregation and configured itself as a space for treating the sick.

According to Amarante (2007AMARANTE, P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz, 2007., p. 25), the medicalization of the hospital had two dialectical consequences: “the hospital became the main medical institution, that is, it was appropriated by medicine, absorbed by its nature; on the other hand, medicine became a predominantly hospital knowledge and practice.” One of the results of this movement was the creation of a scientific model of medicine based on clinical anatomy.

It is important to highlight that Pinel understood that the causes of mental alienation were not reducible to organicist explanations. However, already in Cabanis it was possible to observe a direction towards the anatomophysiological explanation of madness, with the introduction of the concept of degeneration in the field of medicine. In this regard, Caponi (2012CAPONI, S. Loucos e degenerados: uma genealogia da psiquiatria ampliada. Rio de Janeiro: Editora Fiocruz , 2012. p. 60) states that “the psychiatry that began with the theorists of degeneration in the second half of the 19th century maintained and deepened the localizationist ideas outlined by Cabanis, distancing itself from the criticisms that Pinel directed at this explanatory model of mental illnesses” (our translation). The theory of degeneration, originating in France, had a worldwide impact, including on the scientific community in Germany and on Emil Kraepelin.

Even with the influence of theories of degeneration, the movement to reconfigure psychiatry into a form of knowledge based fundamentally on physiology and biochemistry was late and is still a matter of dispute. The development of psychiatry in the United States is a significant example of this scenario.⁵5The North American case was chosen for exposure because it represents the genesis of the articulation between psychiatry and the pharmaceutical industry. The historical development of Brazilian psychiatry, for example, presents a structure somewhat different from that which occurred in the United States of America. To this end, it is worth remembering, according to Amarante (2007), the considerable contribution of the ideas of Kraepelin, and later, Freud, to psychiatric organization. However, despite important differences in its history, the current form of medicalization led by hegemonic Brazilian psychiatry is centered on drug treatment, not fundamentally different from most countries, despite the psychiatric reform recently initiated in Brazil. At the end of the 19th century, the forms of moral therapy for the insane began to be questioned, giving way to “physical treatments,” which included various forms of hydrotherapy, injections of sheep thyroid extract, injections of metallic salts, equine serum and even dental extraction (Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.).

From the 1930s to the 1940s, asylum psychiatry turned to three directly cerebral treatments: insulin coma, convulsive therapies, and frontal lobotomy. It is worth noting that such forms had, at the time, the support of a significant portion of the academic community and the main media, with these treatments being considered miraculous innovations.

In contrast, there was the advancement of word psychotherapies (especially psychoanalysis and behaviorism) and the growing questioning of the weaknesses of the previously mentioned physical psychiatric techniques. However, from an epistemological point of view, there is no antagonism between modern psychiatry and behaviorism since both the field of psychiatry and the behaviorist approach are based on positivism.

Amid such issues and comparison with the scientific development of other areas of medicine, traditional psychiatry entered a major financial and legitimacy crisis (Amarante, 2007AMARANTE, P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz, 2007.; Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.; Szasz, 1980SZASZ, T. S. Ideologia e doença mental: ensaios sobre a desumanização psiquiátrica do homem. 2. ed. Rio de Janeiro: Zahar, 1980.). This crisis is one of the primary hallmarks of psychiatry as a field of scientific medicine. In the European context, based on the microbial discoveries of Ehrlich, Pasteur, and Koch, medical knowledge began to seek and construct more consistent hypotheses of biological causes of diseases. This has been the fundamental medical paradigm ever since. However, in psychiatry, this initiative encountered significant setbacks, so much so that the area was accused of being more aligned with the so-called human sciences than with biological ones (Amarante, 2007AMARANTE, P. Saúde mental e atenção psicossocial. Rio de Janeiro: Editora Fiocruz, 2007.; Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.).

Thus, the lack of a well-defined biological paradigm permeated the transition from alienism to modern European and North American psychiatry,⁶6Keeping the necessary distinctions. as well as part of its early history. The cerebral hypothesis for the so-called mental illnesses, which marked the early 20th century, was unable to even minimally articulate its assumptions with physical therapy. It was at this time that the rapidly growing pharmaceutical industry emerged to profit from the anguish of the psychiatric crisis and the subjects it served.

The alliance signed between the pharmaceutical industry and psychiatry in the mid-1950s is the key to understanding the expansion of the process of medicalization of subjectivity and the epidemic of psychiatric drugs. Such an alliance, under the tutelage of the State, has its most fundamental expression in the North American case. Initially, the American Medical Association (AMA) established itself as the organization that would, together with the Food and Drug Administration (FDA),⁷7FDA is a North American government body, created in 1862, with the function of controlling the population’s food and medicines, through tests and research. evaluate the safety and effectiveness of medicines on US soil. With this, the AMA became “the watchdog of the pharmaceutical industry and its products […], promoting the financial interests and those of its members because its evaluations gave patients a good reason to see a doctor” (Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017., p. 70; our translation). Doctors began to control public access to medicines, becoming a privileged type of salesman for pharmaceutical companies. This alliance was so timely that these professionals began working on promoting new drugs.⁸8The AMA’s revenue from publishing drugs in its media jumped from $2.5 million in 1950 to $10 million in 1960 (Whitaker, 2017).

It was in the context based on this conspiracy that the first psychotropic medicines were launched on the market, in the 1950s. During this period, “the public was eager to know about miracle medicines, and that was exactly the story that the pharmaceutical industry and doctors were eager to tell” (Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017., p. 72; our translation).

It is also important to think that the marketing success of the pharmaceutical industry would require the production of a new type of “mental patient, other than that of the first half of the 20th century. As already mentioned, the determination of the pathological had long been a prerogative of scientific medicine, and, in the context of the insertion of the first psychotropic drugs, this was even more forceful. Freitas and Amarante (2017FREITAS, F.; AMARANTE, P. Medicalização em psiquiatria. 2. ed. Rio de Janeiro: Editora Fiocruz , 2017., p. 33) state that the doctor’s role extended beyond their dual relationship with the patient, after all, psychiatry became the pharmaceutical industry’s fundamental intermediary with the subject. In this relationship, now threefold, the patient was converted into an ill person grouped according to a certain nosological construction, compatible with such purposes: it will be about re-medicalizing subjectivity, now on neurochemical bases.

In this sense, the medicalization of subjectivity is a typically contemporary phenomenon, which unfolds through the requirement of psychiatric knowledge, through ideological commitments to support and legitimize the parameters of capital society. This association unfolds in several instances of social reproduction, such as education, the health sector, and the economy-with emphasis on the role of the pharmaceutical industry and health technologies.

Notably, capital is present in history long before it constituted a system around itself-capitalism (Marx, 2013MARX, K. O capital: crítica da economia política. Livro 1. 31. ed. Rio de Janeiro: Civilização Brasileira, 2013. v. 1.). From the Marxian perspective, capital is a social relationship built on the subordination of living labor, which, once transformed into capital, is converted into dead, quantified, accumulated, and alienated labor. Along these lines, Mészáros (2002MÉSZÁROS, I. Para além do capital. São Paulo: Boitempo , 2002.) understands that even in countries with real socialism, capital continued to determine economic reproduction. Therefore, from these assumptions, we consider medicalization as a typical phenomenon of contemporary societies, in which capital is (or was) the fundamental productive relationship, expressing itself both in capitalist societies and in those belonging to the “socialist field.”

However, in the post-revolution period of 1917 in Russia, based on the influence of historical-cultural psychology developed by Vygotsky, based on historical and dialectical materialism, psychic illness was seen as historically and socially constituted, understood as a product (not exclusively, but determined) of social relations. However, in the so-called Stalinization period of the Union of Soviet Socialist Republics (USSR), the influence of historical-cultural psychology was drastically sidelined, giving way to the conditioning ideas of the physiologist Ivan Pavlov and only returning in the 1960s, from experimental pathopsychology developed by Bluma Zeigarnik, a Lithuanian psychologist and disciple of Vygotsky (Silva; Tuleski, 2015SILVA, M. A. S.; TULESKI, S. C. Patopsicologia experimental: abordagem histórico-cultural para o entendimento do sofrimento mental. Estudos de Psicologia, Natal, v. 20, n. 4, p. 207-216, 2015. DOI: 10.5935/1678-4669.20150022
https://doi.org/10.5935/1678-4669.201500... ).

We also highlight that medicalization should not be reduced to medicamentalization. Medicalization is a phenomenon structured in the consideration of socially undesirable experiences and behaviors as objects of health, therefore, it is not restricted to pharmacological therapy. Medicamentalization. on the other hand, is a particularization of the latter, being “[…] a broad cultural phenomenon that concerns the intersections between drugs, medicine and society and includes patients’ demand for […] medication” (Rosa; Winograd, 2011ROSA, B. P. G. D.; WINOGRAD, M. Palavras e pílulas: sobre a medicamentalização do mal-estar psíquico na atualidade. Psicologia & Sociedade, Recife, v. 23, n. spe, p. 37-44, 2011. DOI: 10.1590/S0102-71822011000400006
https://doi.org/10.1590/S0102-7182201100... , p. 42; our translation). In the field of psychiatry, medicamentalization only emerged as a significant phenomenon in the second half of the 20th century.

From the biologization of subjectivity to the psychotropic fetish

The psychiatric drug epidemic would not be possible without the reformulation of the medicalization of subjectivity based on its biologization.⁹9This has exactly been the movement of hegemonic psychiatry: attributing a certain symptom to a moral (dis)order and trying to understand and explain it biologically. This implies that the pharmaceutical industry, in order to be successful in conceiving a consumer group, would need to reduce subjectivity, as its most fundamental structure, to neuronal functioning. As a result, it became imperative to produce discourses aligned with the ideological purposes of the alliance signed between the pharmaceutical industry and the “new” psychiatry, including its academic facet.

As there is no knowledge production without discursive processes, it is the discursive function that materializes a certain theoretical ideology in language, which, in turn, guides the taking of a position in the production of knowledge. For this reason, the system of theoretical ideologies, typical of a specific social formation, is accompanied by discursive formations that are corresponding and/or contrary to them. In this way, “the process of knowledge production is, therefore, inseparably linked to a struggle over names and expressions for what they designate […]” (Pêcheux, 2014PÊCHEUX, M. Semântica e discurso: uma crítica à afirmação do óbvio. 5. ed. Campinas: Editora da Unicamp, 2014., p. 180, emphasis added; our translation).

As Coser (2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010.) points out, the most efficient way to symbolize the corporate interests of the pharmaceutical industry and psychiatry is through the power of metaphors. With this, the body was metaphorized in the contemporary imagination as a kind of neurochemical machine, whose engineering will work at the pharmacochemical level, “[…] through the chemistry and physics of molecular investigations; in the propagandistic, through icons, analogies and metaphors” (Coser, 2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010., p. 10; our translation). Since the media reproduce such discourses, “we create or give imaginary consistency to these metaphors, which, incarnated, are experienced as the great enigma (or the great answer) that governs each person’s life - serotonin, endorphin…, pharmacological metaphors with which one lives” (Coser, 2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010., p. 10; our translation).

The origins of this enterprise date back to the middle of the last century. However, the cause that requires this type of knowledge from psychiatry goes back to the historical foundations of capitalist society, in its relationship with the process of knowledge production, more precisely with its positivist face.

Mészáros (2004MÉSZÁROS, I. O poder da ideologia. São Paulo: Boitempo , 2004., p. 246) states that, with the need for capital to promote positivism in the first half of the 19th century, “[…] a new type of relationship between science, technology and industry was born, which supported the realization of productive potentialities of society to a previously unimaginable extent”(our translation). This occurred “[…] in part due to a significant qualitative growth in the domain of nature and, in close relation with the latter, to an unimaginable increase in labor productivity […]” (Lukács, 2013LUKÁCS, G. Para uma ontologia do ser social II. São Paulo: Boitempo, 2013., p. 45-46; our translation). With the imperative of expansion and accumulation of capital, natural sciences have become the basic model of knowledge production, since the development of the latter is an elementary condition for the expansion of techniques and technologies that guarantee an increase in economic productivity, in levels compatible with capital needs.

Indeed, the relationship between capitalism and positivism is extremely close, and its basis lies in two central reasons: a) the manipulation of nature with unprecedented efficiency and b) the denial of ontology (Lukács, 2013LUKÁCS, G. Para uma ontologia do ser social II. São Paulo: Boitempo, 2013.). These two reasons are expressed in dialectical unity, and Lukács’ question (²⁰¹³LUKÁCS, G. Para uma ontologia do ser social II. São Paulo: Boitempo, 2013., p. 39), which asks whether “[…] the truths of natural sciences effectively reproduce objective reality or merely enable its practical manipulation […]” (our translation), is fundamental to the progress of this analysis.

Born in the capitalist context, positivism is considered, to this day, the most efficient scientific way of manipulating nature. This extensive focus on the domain of nature brings with it an interesting limitation, which excludes the analysis of the social totality, eliminating the decisive categories of nature and matter, since its activity remains tied to the immediacy of fragmented manipulation, even in the case, for example, of science produced in the so-called “socialist field.”

In positivism,

In this way, fragmentation is the consequence of the reductionism-in this case, biological/cerebral-that characterizes the positivist edifice as a methodological-ideological-discursive enterprise, on which psychiatric knowledge is built, under the determination of the pharmaceutical industry from the second half of the 20th century. In turn, the constitution of this functioning expresses what is understood here as psychotropic fetishism.

The classic and fundamental formula of a fetish is the whole by the part, functioning by synecdoche-there is the production of an effect of universalization of the particular, a procedure in which, in the midst of a given phenomenon, a certain part of it is chosen to be taken as reductive common denominator of the complex in question. As far as this analysis is concerned, psychotropic fetishism operates by reducing subjectivity to the nervous functioning and, from there, human subjectivity can be reduced, ultimately, to the functioning of neuronal networks.

However, the way psychiatry found to structure the psychotropic fetish was already a presupposition of other medical areas. The operation consisted of making medicalization pharmacological, that is, pathologizing (via biological reductionism) and basing its therapy, whenever possible, on the use of medicines. However, the synecdoche in psychiatry still did not have a well-defined plot since previous physicochemical treatments had not stood the test of criticism.

The modern narrative of psychopharmacology emerged, then, in the common irony of much of the pharmacological discoveries of the 20th century: finding a therapeutic effect from unexpected effects. In this way, the beginning of psychopharmacology is in a way an “accident,” as expressed by the pioneering cases of chlorpromazine, meprobamate and chlorodiazepoxide (Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.; Coser, 2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010.). Coser (2010)COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010., in fact, highlights that this regularity also occurred with monoamine oxidase inhibitor antidepressants, other antidepressants, anxiolytics and butyrophenones.

These successful “accidents” allowed the pharmaceutical industry and psychiatry to formulate the biogenic amine hypotheses, their fundamental synecdoche.¹⁰10Currently, the theory of biogenic amines has lost strength as the main explanatory academic model, which does not mean that it is not the dominant model in clinical practice or that the biological explanation as the cause of so-called mental disorders has been abandoned. In short, these hypotheses suggest that the cause of psychological suffering, transformed into mental disorders/illnesses, is a neurobiological imbalance of certain synaptic transmitters.

Notably, the hypothesis that understands subjectivity as centrally determined by the chemical and physiological functioning of the brain log predates the development of psychotropic medications. However, it was due to the empirical use of drugs that this conception expanded. Whitaker (2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.) points out that the theoretical root of the biogenic amine hypothesis emerged in the 1950s, when there was still debate about how signals crossed neurons. However, when it became possible to isolate acetylcholine, serotonin, norepinephrine and dopamine, the chemical synapse model quickly prevailed. Along these lines, from 1955 onwards, initiatives such as those by Bernard Brodie, Arvid Carlsson, Joseph Schildkraut, and Jacques Van Rossum, quickly defended biological hypotheses about the cause of mental disorders/illnesses.

However, such postulates suffered from the same methodological weakness: assuming the pathophysiology of the alleged disease based on the drug’s mechanism of action (Whitaker, 2007WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.; Coser, 2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010.). It was due to the discovery of part of the mechanism of action of the psychotropic drug-its biological response-that the explanation, dominant to this day, was produced that mental disorders/illnesses are the result of physiological imbalances. Thus, the supposed biological causes were suggested by the inverted image of pharmacological functioning. In summary: it was not the causes that determined the therapeutic behaviors, but the opposite, the behaviors-mostly accidental-that determined the cause.

To explain the characteristic discursive functioning of the psychopharmacological fetish, we use the example of one of the most sold and used psychotropic drugs in Brazil, the tricyclic antidepressant (TCA) amitriptyline hydrochloride. Its action results from the inhibition of the neuronal uptake of norepinephrine and serotonin in the pre-synaptic nerve terminal (Rang et al., 2010; Whalen; Finkel; Panavelil, 2016WHALEN, K.; FINKEL, R.; PANAVELIL, T. A. Farmacologia ilustrada. 6. ed. Porto Alegre: Artmed, 2016.). For those who still share the myth of the biological cause of depression, this would be due, above all, to a supposed brain deficit of serotonin, but also of dopamine and/or norepinephrine. In this sense, amitriptyline hydrochloride, by inhibiting presynaptic reuptake, provides the amounts of serotonin and norepinephrine necessary to reestablish “normal” brain activities.

When therapy for depression is centered on the biological action of medication, specifically the use of amitriptyline hydrochloride, the subject of psychiatric care becomes reducible to their elementary biological dimension-their nerve cells. The biological dimension of subjectivity is, then, displaced to the dominant condition of the psychic, which is why the fetishism of the psychotropic drug expresses its elementary meaning effect in the production of the statement: we are our brain. Under these circumstances, the psychiatrist becomes a kind of neuronal engineer.

In this line of reflection, the fetishization of psychotropic medications produces a silencing effect on the socio-symbolic dimension. In other words, the evidence of physiological automation of subjectivity, created by current positivist science,¹¹11Also known under the suggestive term neuroscience. seeks to hide the social determinations of forms of psychological suffering, of which depression is a part. By ignoring such determinations, individualizing and hyper-dimensioning the biological structure of subjectivity, the dominant psychiatric ideology uses the old bourgeois strategy of blaming the victim. In this way, this part of psychiatry serves the purposes of conserving capital society since its procedure implies the limitation of the ability to grasp the complexity of contradictory social relations in this system and thus contest it.

Therefore, the fetishized form of psychotropic drug use is also characterized by its ability to produce strangeness: in this type of functioning, the neural synapses project themselves against the subject that integrates them, like a hostile force that controls them. The subject, reduced to the biological, becomes lost in the “autonomous” movement of the metabolism of its amines. From this discourse, they assume ghostly powers over subjectivity.

However, the ghostly power of the psychotropic drug is not of the supernatural order but comes from the material order structured in the way subjects relate to each other in society. In this way, the social function of the fetishism of psychotropic medicine in capitalism has two complementary and inextricably linked reasons: an economic one, aligned with the imperatives of reproduction and accumulation of capital (specifically, those aligned with the health industrial complex); and an ideological one, resulting from the need to establish a set of discourses aimed at reproducing and maintaining the capitalist form of society, based on control strategies. The pharmaceutical becomes the new alternative for silencing, isolation, and control, previously exercised hegemonically by the asylum.

As a result, the fetishism of psychotropic drugs is structured into another even more embryonic fetish, that of the commodity, the foundation of capitalist society (Marx, 2013MARX, K. O capital: crítica da economia política. Livro 1. 31. ed. Rio de Janeiro: Civilização Brasileira, 2013. v. 1.). Therefore, it is necessary to understand the psychotropic drug also in the form of commodity-medicine. Considering medication as a commodity implies the understanding that its realization permeates the moment of production, circulation, and consumption. Due to the need to have its product commercialized in order to increase capital, the pharmaceutical industry annually invests large amounts of money in maintaining its alliance with psychiatry and in the metaphors that give materiality to the marketing campaigns for its “magic pills” (Whitaker, 2017WHITAKER, R. Anatomia de uma epidemia: pílulas mágicas, drogas psiquiátricas e o aumento assombroso da doença mental. Rio de Janeiro: Editora Fiocruz , 2017.; Coser, 2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010.).

However, the commodity-medicine also satisfies the needs (therapeutic or imaginary) of its users and momentarily relieves certain symptoms of mental suffering, which is why its demand is growing. As a result, the criticism made in this article is not of the pharmacological substance itself, but of the capitalist way it is consumed, which, based on mercantile determination, displaces the drug from the status of symptom reliever, and, through the effect of the metaphors produced, elects it as the core of therapy, giving it the power to affect the cause of the supposed disorder (Coser, 2010COSER, O. As metáforas farmacoquímicas com que vivemos: ensaios de metapisocofarmacologia. Rio de Janeiro: Garamond, 2010.).

The effect of these metaphors is expressed, for example, when, in commercial campaigns and in the statements of users and health workers, psychotropic drugs are mentioned under the headings of antidepressants, antipsychotics, anxiolytics. Therefore, we can observe a functioning in which the user begins to rely on the use of medication with the expectation of being cared for and protected, overlooking the fact that this use, when recommended, is only one of the treatment resources; and that “[…] its effectiveness is dependent on the many other actions that are developed in a given ‘line of care’ that is processed within health services and this is determined by social, technical and subjectivation processes […]” (Franco; Merhy, 2005FRANCO, T. B.; MERHY, E. E. A produção imaginária da demanda e o processo de trabalho em saúde. In: PINHEIRO, R.; MATTOS, R. A. de (Org.) Construção social da demanda: direito à saúde, trabalho em equipe, participação e espaços públicos. 2. ed. Rio de Janeiro: CEPESC/UERJ; ABRASCO, 2005., p. 3, emphasis added; our translation).

Even the psychosocial approach to mental health, the object of the Psychiatric Reform (PR), cannot alone overcome the hegemony of the medication-centered approach, and has gradually been, despite its advances, sidelined and taken as complementary to pharmacological therapy. Yet, as Oliveira (2021OLIVEIRA, J. R. de. Os sentidos do cuidado em saúde mental na estratégia saúde da família. 2021. 204 f. Tese (Doutorado em Saúde Pública) - Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, 2021.) points out, there seems to be no drug therapy at all, but a reduced process of searching for a prescription-consultation-dispensing of medication, thus constituting a cycle of mental health care focused almost exclusively on the use of psychotropic drugs. This is the phenomenon that is the fundamental target of criticism here.

Final considerations

The biological invention of the causes of mental disorders, as it is known today, was largely brought about by the pharmaceutical industrial complex. Such a process is coherent with the capital’s fundamental dynamic of subjugating other social complexes. It was not only psychiatry, but the pharmaceutical industry (sectoral expression of capital) that hegemonized the biologizing discourse of psychic suffering, and psychiatry did not just speak for the industry, it was discursified by it. In a broader dialectical analysis, the role of psychiatry was also to support the legitimization of the pharmaceutical industry’s economic interests.

The ability of psychotropic medication to satisfy certain human needs is not denied, much less the benefits that they can offer to people in psychic distress, after all, we are not just our brains, but we are them to a certain extent. Thus, the aim was not to build a negative understanding of pharmacological development and improvement. What we sought was to criticize the foundations of the capitalist way of consuming and prescribing psychotropic drugs. Therefore, the analysis necessarily involved a critique of the model of social metabolism that capital imposes on subjects, in the hope that we can go beyond fetishized therapy and show that drugs are social products and that the subject is more than their biological dimension.

Finally, we hope to contribute to the practices of those who fight for the legacy of the anti-asylum movement and thereby add to the efforts of those involved in the production of effectively humanized and critical practices, whose raw material is therapy with high doses of welcoming, qualified listening, affection, empathy, and autonomy.

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