Let Them Eat Prozac
By David Healy
Lorimer, 462 pages, $29.95
Before Prozac, few people risked getting depression. Now, it seems, we are all at risk. Better pay close attention, then, to David Healy's wonderfully perspicuous account of how a treatment can manufacture disease.
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Of course, depression has always been with us, and Healy presents some moving stories of how this disease can blight the lives of those affected. The great boom in depressive illness, however, dates back only to the discovery and marketing of Prozac.
Prior to the 1990s, comparatively few people were thought to suffer from depression: perhaps one person in 10,000. With the discovery of the Prozac family of drugs there came, not coincidentally, an explosive increase in diagnoses of depressive illness.
Current estimates claim that one in 10 of the population is clinically depressed. A thousand-fold increase. In barely a decade, depression has gone from being a rare disorder to being classed as one of the greatest afflictions of humankind -- requiring that millions of comparatively healthy people be treated with powerful medication. An old cliché jumps irresistibly to mind: To the man with a hammer in his hand, everything looks like a nail.
As one of the first researchers to investigate the serotonin reuptake mechanisms in depressed people, Healy was in the vanguard of the SSRI revolution that gave the world Prozac, Paxil, Zoloft and Celexa. He has been a consultant for many of the leading players -- Eli Lilly, Pharmacia and Upjohn -- and has spoken at international symposia for Pfizer, SmithKline Beecham and AstraZeneca. Harvard University Press has published two of his dozen books. Little wonder, then, that the University of Toronto faculty of medicine was initially thrilled to recruit Healy to its department of psychiatry.
In the world of psychopharmacology, Healy is an insider's insider. This inside track makes his account of the sordid underbelly of the drug industry both more believable and more disquieting. He really does know where the bodies are buried, literally as well as figuratively, and readers will find their confidence in the integrity of drug research badly shaken.
Although Healy was an early advocate of Prozac, his clinical research persuaded him that the Prozac drug group could trigger suicide and violence in some patients. Later, when he gained access to internal company communications, he discovered that the companies themselves knew of the problem.
Healy concludes that SSRIs might benefit some people in the short term, but he finds little reason to think that they help things to turn out better in the long run. Most worryingly, he presents persuasive evidence that the SSRIs make a significant number of people suicidal and a larger number addicted.
There is no nice way of putting this: The drug companies have subordinated patient safety on the altar of blockbuster profits. Aggressive marketing has persuaded the medical profession to prescribe SSRI drugs to people who are simply struggling with mundane anxieties. Unwilling to risk the death of a goose that lays such golden eggs, the companies refuse to sponsor the kind of large-scale scientific research that would map out the true frequency and seriousness of side effects. Absent such research, doctors and patients are unable to make properly informed choices.
There may be only 50 ways to leave your lover, but there are at least 150 ways to design drug experiments so that they are skewed in favour of the sponsoring company's products. From my own research on the ethics of clinical trials, I thought I knew all the tricks of the trade. I was mistaken. Healy has taught me some new ones.
Want to eliminate evidence of dangerous side effects from your new anti-depressant? First, ensure that company scientists design the experiment and tabulate the data before it is turned over to the university scientist whose name will grace the eventual publication. Better yet, when volunteers enrolled in the experiment become agitated (and potentially suicidal or violent), code them as "failing to respond to treatment." Amazingly, by this simple sleight of hand, the alarming side effects disappear. What isn't recorded doesn't exist. The respected scientist whose name goes on the ghost-written publication -- a widespread practice, as Healy shows -- seldom sees the raw data and is happy to collect a generous fee from the company along with the status that comes with having "his" research published in a prestigious journal.
Leading drug industry figures play an unsavory role in this story, but it cannot be said that either the medical profession or government regulators emerge with armour shining. Those charged with protecting the public from unjustifiable harms seem not yet to have taken on board the central lesson of the 1962 thalidomide tragedy: All drugs are inherently risky. Only honest and well-designed research can tell us which drugs offer which patients the likelihood of more benefit than harm.
Because universities and hospitals float on a sea of drug company money, few seem keen to raise critical questions about unethical research practices. Moreover, when researchers demonstrate moral courage by going public with evidence of harmful side effects, they may find themselves sued by the company (Toronto doctor Nancy Olivieri for example, was threatened with legal action by a pharmaceutical company after she told her patients of the potential dangers of a drug she was testing on them. Others risk termination).
Let Them Eat Prozac tells a compelling story, with strong resemblances to a detective novel. The drama of Healy's personal odyssey, from pro-industry scientist to embattled critic, illuminates the dark side of the bargain between modern science and Big Pharma. The book is edifying and frightening. But never depressing.
Arthur Schafer is director of the Centre for Professional and Applied Ethics at the University of Manitoba. His study of pharmaceutical research ethics is forthcoming in The Journal of Medical Ethics.
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