Prof. Peter Saunders reviews
David Healy. Let Them Eat Prozac. New York University Press, New York and London. 2004.
Hardback ISBN: 0-8147-3669-6
Anti-depressants are among the most profitable drugs produced by the pharmaceutical industry. In 2005, the last year for which there are full data, 170 million prescriptions for antidepressants were filled in the USA [1].
In Let Them Eat Prozac, David Healy, professor of psychiatry at Cardiff University and an acknowledged expert in psychopharmacology, shows how the efficacy of the drugs has been very much exaggerated and their dangers very much played down. He also describes the lengths to which the industry has gone to promote the widespread prescription of anti-depressants and to avoid responsibility for their side effects.
You may have heard of Healy because of what happened in 2000 [2]. He had been appointed as a professor of psychiatry at the University of Toronto, but just before he was to take up the post, he gave a lecture in which he discussed some concerns about anti-depressants and pointed out that there had been no research into how to minimise the risks. The University withdrew its offer, and while it has consistently denied this was due to pressure from the pharmaceutical industry, it is hard to imagine any other reason. Healy sued the University for breach of contract, libel, and breach of academic freedom. In the end a mediated settlement was reached and the University repaired the libel by appointing him a visiting professor [3].
That was not, however, his first clash with the pharmaceutical industry. The book begins with a brief history of the development of selective serotonin reuptake inhibitors (SSRIs), including what was for me the surprising fact that depression has only been a major recognised condition since antidepressants were developed. Before that, only about one person in ten thousand was thought to suffer from what was then called melancholia; now it is one in ten. Presumably because of this, the discovery of antidepressants was not considered at the time to be a great breakthrough. It was also recognised right from the beginning that antidepressants might lead to suicide. That was not a reason for not developing them, and it does not mean that psychiatrists should never prescribe them, but it's something that both researchers and clinicians should keep in mind far more than they have done.
Healy describes how he gradually became more and more concerned both with the evidence that antidepressants are less effective and more hazardous than was generally recognised and also with the attitude of the industry, which singularly failed to deal with his concerns, and was consistently either ignoring evidence or interpreting it in a way that put the drugs in the best possible light. For example, they would draw attention to a result that showed one drug was more effective than a competitor without mentioning that neither was better than a placebo.
Healy describes cases in which he was called in as an expert witness and found himself observing, and experiencing, the great pressure that the drug companies are willing to deploy to defend their profits. These are fascinating stories and I would have enjoyed them if they had been episodes in a novel by John le Carré rather than about real life.
As the title implies, this is essentially a book about anti-depressants and especially about Lilley's Prozac. Healy points out, however, that much of what he describes is not confined to psychiatry. He describes how control of the scientific media makes it possible for companies to build up a bandwagon in one area while others remain neglected. In the 1960s, for example, there were two competing views on the most important factors in preventing heart attacks. One was that blood lipid levels were the key, and this has led to the development of highly profitable drugs for reducing them. The other hypothesis, that high levels of homocysteine (an amino acid in the blood) were important, was largely neglected until quite recently. The homocysteine hypothesis has the advantage (or the disadvantage, if you are a pharmaceutical company) that it suggests a range of dietary treatments rather than a drug [4].
An important part of the process is ghost writing. Many papers in scientific journals are written not by the authors whose names appear on them but by employees of medical information companies. This is not just a matter of an editor putting a busy researcher's notes into publishable form: the initiative is often taken by the ghost writer with the scientists only seeing the paper at a late stage. The role of these companies is clear from a description that used to appear on the website of a New York based firm, Current Medical Directions: "to deliver scientifically accurate information strategically developed for specific target audiences." [5].
Reading what Healy has to say, we see that when Aubrey Blumsohn complained that he hadn't been allowed to see the raw data that the paper he was an author of was based on, and that an abstract in his name had been sent to a conference before he had seen it, what he was objecting to is standard practice. What was unusual was not that these things had happened but that a scientist had objected to them [6] (Actonel: Drug Company Keeps Data from Collaborating Scientists, SiS 30).
Healy also describes how difficult it can be to get information about clinical trials and the way that positive results are far more likely to be published than are negative ones. This obviously conveys a false picture of how effective a drug is [7].
Healy writes well, but his book is not an easy read. He is asking you to believe some pretty alarming things about companies that you may have thought were all about helping people, and he doesn't expect you to take what he says on trust. The science is explained in detail, and chapter and verse are given for everything, even more than we do in SiS. There are 51 pages of notes and references at the end; and still more information, including the contents of letters and transcripts of courtroom proceedings, is available on a website [8].
Earlier this year, I attended a debate at the Institute of Psychiatry in London. The motion for debate was "This house believes that psychiatrists are unable to resist the seductive messages of the pharmaceutical industry" and Healy was one of the speakers. What struck me most as an outsider was that even those who spoke against the motion did not try to defend the industry's marketing methods; they argued only that psychiatrists are capable of resisting them.
In the end, the majority view was that psychiatrists are able to make up their own minds. As for myself, I was more convinced by the doctor who chaired the debate and began by saying that he had never met a psychiatrist who admitted to being overly influenced by the drug companies, but he had met many psychiatrists who knew others that were.
I described all this to a friend who is a psychiatrist (and who, like Healy and I expect all those who participated in the debate, uses psychopharmaceuticals in her work) and she said she agreed with a lot of what had been said on both sides. But, she added, a lot of the prescribing of antidepressants is done not by psychiatrists but by general practitioners, who are far more likely to accept what they are told by drug company representatives or supposedly independent speakers at meetings [9].
If you are interested in what happens to science when it becomes part of big business, as we have described with genetic modification in many issues of SiS, you should read this book. I'd recommend it too, to anyone who is suffering from depression or has a friend or relative who is. And give a copy to the doctor too.
Article first published 11/08/08
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