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The timing of David Healy's talk couldn't have been better. Two weeks ago, the U.S. Food and Drug Administration gave the order to the makers of the top 10 antidepressants to put a warning on their products that people using the medication could experience a possible increase in suicidal thoughts and behaviour. Invited by McGill's Biomedical Ethics Unit and the Clinical Trials Research Group to speak on "How Pharmaceutical Companies Manufacture Cultures," Healy gave a rapid-fire survey course, complete with slides, on just how the boom in the prescription and consumption of antidepressants, anxiolytics (anti-anxiety medication) and their kin came to be.
Noting that only a generation or two ago no one spoke of depression, anxiety, panic attacks, post-traumatic stress disorder (PTSD), or social phobia - only of "bad nerves" - Healy, a professor of psychiatry at the University of Wales, and author of "Let Them Eat Pizza" told the 300 listeners that the psychopharmaceutical industry discovered that by selling illnesses, they could sell pills.
Although anxiolytics have been around since the 50s, when chlorpromazine (sold as Valium and Librium) was discovered to calm patients in psychiatric hospitals, it was only in the 70s that it became widely prescribed, argued Healy. "She's talked. You've listened. But there she is again," went the slogan on the slide of an advertisement for Valium. She was "anxiety" - then the catch all name for nervous or mild psychological disorders.
Then came the Diagnostic and Statistical Manual of Mental Disorders (DSMIII). The tome was a catalogue of psychiatric disorders put out in 1980 by the American Psychiatric Association, and it divided anxiety neuroses into the categories of panic disorder, social phobia, PTSD and depression. "Upjohn [pharmaceuticals] realized that the DSM had created a niche for panic disorder, so they marketed the illness rather than the pill. "People in the U.K. didn't buy the drug but they knew about 'panic attacks,' which, in fact, included the same symptoms as the woman 10 years earlier.
"Upjohn, through convening meetings with physicians, fostered an awareness of the illness which was covered by the likes of the BBC, CBC and the New York Times."
Then it became a question of time before citizens' awareness of the symptoms of panic attacks, for instance, would increase and they would alert their general practioners, who would be ready with the appropriate medication.
To underline his point regarding people's vulnerability to media reports on one nerve malady or another, Healy showed a slide comparing the consumption of antidepressants in the 90s in Japan and South America, where there were fewer media reports of depression, to that of North America and the United Kingdom. "The consumption of anti-anxiety pills is robust and steady but there is no increase in antidepressants.
"The Japanese stayed anxious and they didn't get depressed," he said, gaining laughs from the audience. "It's the same model in South America."
In our part of the world, however, the consumption of Selective Serotonin Reuptake Inhibitors, (SSRIs ), the main category of antidepressant medication, saw a marked increase.
"I'm trying to give you a feel for how these companies engineer change," he said as he showed slides depicting the depressed patient. In the 60s, depression is expressed by an old woman or old man saying "Doctor, I feel awful." Depression in the 90s is shown afflicting young, attractive women and, later, men. At the same time, the media continues to report increasing degrees of depression. "Are we a low-serotonin population?" quipped the British broadsheet The Guardian after yet another study. "That's how we lost the empire," joked Healy.
What is no joke, however, is the potential for increased risk of suicidal thoughts and actions. And this is where Healy, a practitioner as well as researcher, questions the manner in which the results of studies conducted by the pharmaceutical industry are reported in reputable medical journals such as The New England Journal of Medicine. You may remember that Healy was the psychiatrist hired in 2001 at the University of Toronto who lost his position following a talk he gave entitled "Psychopharmacology and the Government of the Self" in which he expressed the opinion that research on the effectiveness and the risks of psychotropic drugs was inadequate and poorly reported in the medical journals. At his McGill talk, Healy reiterated that he would like the pharmaceutical companies, whose studies are sometimes written up by such medical communications firms as Current Medical Directions, to make the raw data from their studies available.
What happens, explained Healy, is that after an article is ghost written by a medical communications firm, the pharmaceutical company will send it to several academic psychiatrists for approval and their eventual signatures as authors (subject to small changes or corrections), thus giving the article legitimacy. Too often, he said, when an increased risk of suicide is associated with an antidepressant, as compared to those taking a placebo, it isn't reported as such. In the case of Paxil, for instance, a popular antidepressant made by GlaxoSmithKline, there were five "suicidal acts" reported out of 93 subjects, where there were none among depressed people given a placebo.
The study did report that some subjects taking the drug showed "emotional lability," a term Healy later learned from insiders at the company, which included suicidal thoughts or actions. Anyone reading the article, however, would have had no hint that there is a significant risk of suicidal activity associated with Paxil.
Acknowledging the power of the pharmaceutical industry and the fact that some of the medication helps some of the people some of the time, Healy appealed to the physicians themselves to force the industry to be more honest with their research findings.
"The big failing in this story is academic and clinical psychiatry and medicine. We have to say, 'Yes, you can publish this article with my name on it, if you make the raw data available.' The problem is not with the ghost writing, but with the lack of data."