In a recent (and still ongoing) series on Robert Spitzer and the DSM, I touched on some of the history of the difficulties in separating out the diagnosis of depression from both bipolar and anxiety (part of what Freudians used to call neurosis). A different historical perspective is offered by David Healy MD (pictured here) of the University of Wales. I originally published this in an email newsletter back in Nov, 2003, and it has been featured on my website since Dec, 2003:
Consider these scenarios: A patient back in the seventies complains of "nerves" or anxiety and is sent out the door with a tranquilizer (benzodiazepine) such as Librium or Valium. A few years later, that same patient might be asking for Xanax for her panic attack. In the mid-nineties, we have the same patient with the same symptoms telling her doctor she has depression. Today, the same patient is likely once again to complain about anxiety.
Much of the credit for how we understand ourselves goes to the pharmaceutical companies, even if we don’t take meds, David Healy MD of the University of Wales said in a grand rounds lecture at UCLA on Oct 28, 2003 and webcast the same day. Upjohn (since taken over by Pfizer) pioneered the concept of marketing the illness rather than the drug, capitalizing on the DSM-III’s reclassification of anxiety into several disorders to push Xanax for panic disorder. In the mid-eighties, as the benzodiazepines became a focus of concern, the SSRIs in development were first seen as non-habit-forming alternatives to tranquilizers before they were targeted to treat depression. More recently, the SSRIs are returning to their original purpose, with the drug companies spending up to $100 million a year to promote these meds as "anxiolytics" (thereby distinguishing them from the bad associations of tranquilizers).
A thorn in the side of the psychiatric establishment, Dr Healy is the author of "Let Them Eat Prozac" and a dozen other books, has published articles on the suicidal side effects that some patients can experience on antidepressants, has appeared as an expert witness in legal actions against Prozac and Paxil, and recently sued the University of Toronto for rescinding an employment offer. According to Dr Healy, in order to create new markets for its products, the pharmaceutical industry ghost-writes much of the literature that appears in mainstream psychiatric journals, mobilizes expert opinion, designs its own drug trials, engages in extensive media campaigns, and underwrites (and even establishes) patients’ groups.
Dr Healy stressed to this writer that he is not hostile to the industry, simply stating that its influence needs to be recognized.
During the 1990s, Dr Healy went on to say, we converted cases that would have been treated by Valium and Librium into cases treated by Prozac, Paxil, and Zoloft. Back in the 1960s, an Eli Lilly print ad for a tranquilizer showed a young mom playing with her daughter. Another Lilly ad from the same period, by contrast, displayed the face of depression as an elderly woman. Back then, he reminded his audience, depression was regarded as a rare illness affecting mainly older people. In 1996, when the World Health Organization reported that depression was the second greatest source of disability on the planet, the reaction from psychiatry was not how did society become depressed so fast, but rather "we’re the second most important people in medicine after the cardiologists."
But this trend was far from universal, Dr Healy pointed out. During the nineties, the Japanese did not become depressed the way we did. Prozac is not on the market there [Note: this has since changed], and tranquilizer use remains vastly greater than antidepressant use. Most of the rest of the world, Dr Healy reminded his audience, follows the Japanese model.
Which raises the $64,000 question: Are we better off with antidepressants? The answer may elude us, if we follow Dr Healy’s reasoning. Randomized clinical trials, he says, were never meant to prove a treatment works. Rather, they are designed to show something doesn’t work, as in the case of a charlatan promoting snake oil. It is industry’s "greatest achievement," claims Dr Healy, to turn this around. Although he does prescribe antidepressants in his clinical practice, one senses it is with the confidence of one recommending a Tylenol for unexplained pain than an antibiotic to knock out a particular infection. Indeed, he concluded, if SSRIs worked for depression or anxiety the way antibiotics do for GPI (syphilis), we wouldn’t have the illness around anymore.
Don’t expect this guy to be the guest of honor at any industry-sponsored symposia.
In his UCLA grand rounds lecture, and in an internet article, Dr Healy gave several examples of how pharmaceutical companies influence medical and public opinion. One of these involved the company, Current Medical Directives (CMD), which ghost-writes and coordinates medical articles for its clients. As part of a legal action against Pfizer, Dr Healy obtained access to a document that listed the progress of 85 articles on Zoloft. Two articles in preparation related to Zoloft and PTSD, for which Pfizer was seeking a license. The authors were listed as "TBD," for "to be determined." The articles eventually appeared in JAMA and the Archives of General Psychiatry, with several academic psychiatrists credited as the authors. In a study published in the British Journal of Psychiatry, Dr Healy found that the 85 CMD articles were cited three times more often than non-CMD Zoloft articles. One hundred percent of the CMD articles reported favorable results for Zoloft vs 44 percent of the non-CMD articles.
Another example involved six academic articles on pediatric depression, with the authors hailing Paxil as "effective, safe, and well tolerated," despite clear evidence of suicidal thinking and behavior in some patients, greater than those on the placebo and comparison drugs. Since then, citing the same data the academic authors had access to, authorities in the UK have advised against prescribing Paxil to patients under age 18 while the FDA in the US has announced strengthened warnings on product labeling.Postscript: In 2004, following two highly-publicized public hearings, the FDA announced that black box warnings advising of increased suicidal risk for non-adults would appear on antidepressant product labeling.