Depression and the grand delusion

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Depression and the grand delusion - Financial Review

Sat, 2 Oct 2004 11:23:39 -0400

 

 

Financial Review

 

Depression and the grand delusion

Cheryll Barron | Prospect Magazine

2004/10/01

 

http://www.afr.com/articles/2004/09/30/1096527854080.html

 

Depression is an epidemic, and the best weapons against it are

prescription drugs called selective serotonin re-uptake inhibitors

(SSRIs). We all have a substance called serotonin in our brains and

low levels of it are the cause of depression. SSRIs work by bringing

them back to normal. The pills have unpleasant side-effects for some

people, but this is outweighed by the relief they offer from

wretchedness. This has been the prevailing view in medicine for nearly

two decades, during which time the prescribing of antidepressants in

the United States has tripled - more than 100 million prescriptions

were written last year.

 

But change is afoot. The depression model centred on low serotonin has

been seriously undermined by hard facts dug out of medical research by

public health activists - chiefly in Britain (possibly because it is

the natural home of glum stoicism). Those facts are set out in a new

book: Medicines out of Control? Antidepressants and the Conspiracy of

Goodwill. It is a carefully substantiated and elegantly written

indictment of the drug companies that make SSRIs, explaining why their

claims for the benefits of the drugs are unfounded, and who has hidden

this information from us and how. It is a classic expose and an

essential corrective to the 1990s bestsellers on antidepressants -

Listening to Prozac, Prozac Nation, and The Noonday Demon - all of

which examined the pros and cons of the new generation of

antidepressant drugs and concluded strongly in their favour.

 

The book's chief author is Charles Medawar, director of Social Audit -

a British spin-off of Ralph Nader's Public Citizen network - and a

blistering critic of modern medicine from deep within the fold of

Britain's scientific and medical elite (his book's subtitle is

borrowed from the writings of his father, Peter Medawar, who won the

Nobel prize for medicine in 1960). The drug companies want their drugs

to work well, just as much as doctors and patients do, but all three

groups, along with government regulators, conspire to promote a " grand

delusion " that hugely overestimates the effectiveness of pills.

 

The book explains the background to some of the intriguing scraps of

bad news about antidepressants that have emerged in recent months. In

May, the New York Attorney-General, Eliot Spitzer, filed fraud charges

against Glaxo SmithKline - the world's second-largest drug maker - for

hiding negative findings of clinical trials of the SSRI called Paxil

(Seroxat in the UK). In March, the food and drug administration in the

US warned, for the first time, that both adult and juvenile patients

on SSRIs can become suicidal in the early weeks of therapy, and it

asked drug companies to display prominently details of possible

side-effects on labels for these medicines. That announcement came

weeks after the revelation in a book by a Rutgers anthropologist,

Helen Fisher, of how SSRIs can disrupt the sex drive. In late April, a

Lancet editorial about the role of antidepressants in child suicide

condemned " the medical and pharmaceutical establishment " for hiding

vital evidence of the risks. " The idea of a drug's use being based on

the selective reporting of favourable research should be

unimaginable, " it proclaimed.

 

Since last autumn, newspapers on both sides of the Atlantic have

carried reports of drug companies refusing to release research

evidence that SSRIs have virtually no benefits for children. But they

failed to explain why one of these drugs was cleared by the FDA for

use by juvenile patients last year. That drug, Prozac, was also the

lone exemption from the list of SSRIs that Britain's department of

health warned doctors against prescribing to adolescents last December.

 

So why was Prozac spared? The answer in Britain, Medawar and his

co-author Anita Hardon tell us, is that government-appointed

investigators into the effects of SSRIs on children found that " about

one child in 10 might be helped by Prozac: the benefits for them were

presumed to outweigh the lack of benefits or risks to the other nine " .

In other words, the British authorities, like their American

counterparts, gave doctors a green light for medicating nine out of 10

child patients with a drug with no measurable benefits for them at all.

 

The FDA, still looking at drug company studies of the risks and

effectiveness of antidepressants for children, has so far decided not

to follow the British authorities in advising against prescribing

SSRIs for them. Never mind that an analysis of those studies and

several others by British university researchers, published in the

Lancet on April 23, said that four widely used SSRIs did seem to

increase the risks of children thinking of, or attempting, suicide.

 

An intriguing footnote about halfway through Medicines out of Control?

tells of a private session during a World Health Organisation

conference on adverse drug reactions in Sweden in 2001, at which there

was earnest discussion of John le Carre's novel The Constant Gardener,

which is about drug company intimidation of government regulators. And

what these authors have to say supports much of le Carre's argument -

and even his dire pronouncement, in an essay in the Spectator, that

the drug companies, " whether they know it or not, are engaged in the

systematic corruption of the medical profession, country by country " .

If we have learned little of this from the media, he wrote, it is

because the subject is " too complicated, often deliberately, for the

layman " .

 

Just how complicated is clear from even a brief summary of Medawar's

and Hardon's upending of the depression model. For a start, the

" selective " in SSRI turns out to be unwarranted. " Prozac, " Elizabeth

Wurtzel wrote in Prozac Nation, " is very pure in its chemical

objectives ... and tends to have fewer side-effects. " The truth,

Medawar and Hardon say, is that SSRIs are " highly unspecific and

unpredictable in action " . It turns out that the term " selective

serotonin re-uptake inhibitor " came not from any hard-won insight into

the cause of depression from medical research, but was coined as a

marketing device. SmithKline Beecham (as it then was) - the company

behind the antidepressant paroxetine (sold as Paxil or Seroxat) - had

to find some way of catching up with the market leader, Prozac, made

by Eli Lilly. SKB knew that " paroxetine made more serotonin available

than competing drugs " . Though there was no " clinical evidence " that

more serotonin was better, SKB " decided to emphasise the unparalleled

importance " of this brain chemical for curing depression. Noting the

market's spectacular response to this spotlighting, other companies

began to call their products " SSRIs " too.

 

There is, in fact, no proof that depression is a " deficiency disease "

caused by a lack of brain serotonin. In trials, Medawar and Hardon

say, SSRIs do no more good than other antidepressants on the market,

like lofepramine, which cause no change at all in serotonin levels. A

second reason for scepticism is that while SSRIs increase the level of

this chemical almost immediately, antidepressant effects take at least

two weeks to begin. " If serotonin were a simple key, " the authors

argue, " why would antidepressants not work in about one case in three

and often prove hardly more effective than a placebo? "

 

It was not until the late 1990s, roughly 10 years after SSRIs began to

be widely prescribed, that results from several controlled studies of

them were examined together. These comparisons suggested that placebo

effects did in fact " account ... for about three quarters of the

benefits misleadingly attributed to drugs " .

 

The fact that SSRIs do not really work as advertised is bad enough,

but that is not the worst of what the book has to say about them. It

lays out the evidence from many quarters - including drug companies'

own research - of their addictiveness and side-effects. Unwanted

reactions have a lot to do with the - highly unselective - action of

the pills, and follow from serotonin being " widely distributed in the

body " . Addiction is the worst of the more common, unwanted effects,

and Medicines out of Control? describes the lengths to which drug

companies have gone to obscure or conceal the facts about this. The

consequences of stopping treatment with SSRIs can include insomnia,

depressed libido, shock-like sensations in patients' heads, and suicide.

 

In an internal company memo that Medawar and Hardon quote,

GlaxoSmithKline instructed its PR department to tell the media that

" discontinuation problems are completely different to addiction or

dependence " . This even confused doctors, who were not asked to watch

for symptoms of dependence. Government regulators in both the US and

UK - portrayed here as craven and corrupt - were persuaded to inform

the public that SSRIs were not habit-forming. It was left to European

regulators to resist drug company pressure and insist on the packaging

mentioning " withdrawal reactions " .

 

There are a few bright spots in this melancholy picture. One was the

blocking by the European parliament in 2002 of a proposal that would

have seen Europe following America by allowing direct-to-consumer

advertising of prescription drugs. Medawar and Hardon show how the

SSRI makers expanded the US market for their products through a

combination of lavishly funded advertising campaigns and teams of

" sponsored experts " who redefined depression from the 106 officially

recognised categories in 1952 to 357 variants in 1994. " Shyness " and

" embarrassment " were reconceived by the drug company marketing

departments as " social anxiety disorder " or SAD, which " out of the

blue ... became America's third most common mental illness " . In

America, direct advertising " produced the 'patient pull' that resulted

in millions of prescriptions for SAD " .

 

Although well written, Medicines out of Control? demands close

attention. The reward for slogging through its complexities is the

feeling, at the end, of having been given both a microscopic and

telescopic understanding of its subject.

 

*Medicines out of Control? By Charles Medawar and Anita Hardon.

Transaction.

 

Cheryll Barron is a former computer correspondent for The Economist.