LET THEM EAT PROZAC: A Book Review Essay

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LET THEM EAT PROZAC: A Book Review Essay

By RFD Columnist Crowe

The question that I could not get out of my head after reading Healy's

book Let Them Eat Prozac [Healy, 2003] was how the author could still

believe in the prescription of drugs for depression and related

psychological conditions. He portrays drug companies as mammon-worshipping

zealots, doctors as automatons with buttons pushed by detail men, the drug

regulators as obedient poodles, judges obsessed with the gnat on the moss on

the branch of the tree while the whole forest is burning and universities

hypnotized by a dollar sign swinging slowly back and forth in front of their

eyes. Science is just a front for making money, clinical trials are designed

to show nothing embarrassing (or suppressed if they do), and all the

anti-depressant drugs have serious side effect, some fatal. Oh yes, and most

people don't even need the drugs as mild depression generally resolves

within a few weeks. Yet, even with all this, Healy would still prescribe.

Healy is well known, particularly in Canada, where he lost a prestigious job

at the University of Toronto's Centre for Addiction and Mental Health (CAMH)

because he made a speech in which he detailed the link between Prozac and

suicide. CAMH is heavily funded by Eli Lilly, the manufacturer of Prozac

(although there appears to be no evidence that Eli Lilly lobbied the

university for Healy's removal [schafer, 2003]). The University quickly and

clumsily emailed Healy and withdrew the job offer. Healy may have benefited

from the " Olivieri affair, " where the university also gave no support to a

researcher who ran into trouble with a drug company. Fellow researchers,

however, rallied around in both cases, resulting in the withdrawal of some

of the punishment being meted out for publicly voicing concerns about

adverse drug reactions. Although the reputation of the University of Toronto

suffered the most in both cases, neither researcher escaped unscathed. Both

drugs involved, Prozac and Deferiprone, are still on sale, at least in some

countries.

Depression rose to prominence as a heavily treated mental disorder in the

late 1950's and its growth has paralleled the growth of the pharmaceutical

industry since then. According to Healy, the frequency of depression has

grown a thousand times since antidepressants were first introduced.

Healy's basic thesis is that drug companies knew about the restlessness and

suicidal ideation that the new anti-depressants could produce before they

were marketed, but that they have expended enormous effort to deny this,

along with other problems, such as dependency and withdrawal symptoms.

The public has been conditioned to believe that many mental conditions are

due to chemical imbalances in the brain (often forgetting that there are

other, more concrete reasons, such as the death of a loved one,

unemployment, marital discord, serious physical illness or addiction). When

researchers started blaming low levels of the neurotransmitter serotonin for

depression, the race was on to find drugs that boosted these levels. Healy

calls this belief a myth, but it resulted in the development of the newest

family of anti-depressants, the SSRIs (Selective Serotonin Reuptake

Inhibitors), including Prozac, Zoloft and Paxil.

These new drugs were marketed in concert with diseases. 'Educating' the

public about a deadly new disease, such as Social Phobia, Obsessive

Compulsive Disorder, Generalized Anxiety Disorder or Panic Disorder has

proven highly profitable for the drug companies that can best persuade

doctors that they have the best drug to solve the problem they have created,

and that can drive patients to identify with the condition and demand a pill

to fix it.

Healy waffles on whether these new conditions really exist or not. At times

he seems to scoff at them, but at other times takes these newly identified

conditions very seriously, and supports the use of drugs to solve them. This

may be due to his revulsion at those who are totally opposed to drugs for

mental disorders.

Among the 'fringe groups', the one that causes the most discomfort for Healy

and most other psychiatrists is Scientology. Both sides have thoroughly

demonized each other, so there is great irony when Healy found, when working

on a Prozac-related court case, that one member of the legal team was a

Scientologist. He seems most surprised because this woman appeared to be a

normal and well adjusted human being. Worse yet, she claimed that she once

had been messed up, and Scientology had turned her life around. Healy was

concerned about his ability to continue to work in the pharmaceutical

research industry, so hooking up with a scientologist on a court case was

not a smart career move but it does show a great deal of integrity and

bravery as well as illustrating his naïve belief that modern psychiatry is

genuinely interested in searching for truth.

One of the strengths of this book is that Healy has been involved in several

court cases, and the descriptions of them are quite gripping. The case of

Forsyth is one of the most compelling. He was having some

difficulties adjusting to retirement, but had never been a violent man, and

his problems were not severe. However, 10 days after going on Prozac he

butchered his wife and then killed himself. If this was an isolated

incident, it would be impossible to blame the drug, but Healy describes

several similar cases.

More intellectually convincing is the evidence that healthy volunteers

experienced suicidal thoughts on the drug. Prior to the launch of Prozac in

1988 it was known that restlessness was associated with its use. One trial

reported this in fully one-quarter of participants. In another trial,

suicide attempts occurred in about 1% of patients.

A major focus of Healy's book is how drug companies can manipulate their way

around embarrassing facts like this. One technique is to include the

'washout' period in trials, the time when people are stopping prior

medication before starting the study medication, and use it as a placebo

period. However, if patients are suffering from withdrawal from the previous

drug, the risk of suicide during that period is high, and can help obscure

an increased risk in the study drug.

None of the SSRIs are supposed to be addictive, but Healy musters evidence

that many are. Ironically, withdrawal symptoms help convince many doctors

and many patients that the drugs are effective because every time they try

to stop them their symptoms worsen. Unlike some drugs that have a

relatively short withdrawal period, Healy believes that withdrawal symptoms

from SSRIs can last for several years!

Drug companies not only have a big influence on clinical trials and spend

huge amounts of money on marketing, but they also vigorously defend their

drugs in court. They will do their utmost to win or, as a backup plan, reach

an out-of-court settlement (hopefully with a nice tight non-disclosure

agreement). There is much black humour in the bizarrely evasive statements

of drug company executives in court that Healy quotes. When it is beneficial

to their company, they are happy to portray themselves as morons to avoid

saying anything incriminating. No legal tactic appears to be beneath them.

This is perhaps not surprising, considering that billions of dollars in

sales are at risk if they were to lose a court case. The fact that there is

a financial reason for this behaviour doesn't make it any less shocking or

immoral.

Another major player in the approval of drugs is the regulator, such as

the US Food and Drug Administration (FDA). Healy has some very bizarre

statements to make about them, explicitly stating (twice) that their role is

not to ensure that medicines are safe and effective. The FDA appears to be

unaware of this. In fact, their mission statement states their role includes

" assuring the safety, efficacy, and security of human and veterinary drugs " .

[FDA, 2004] Healy lets them off the hook for corruption and incompetence

by making them irrelevant. He states that " It is not clear that, if the FDA

were to vanish, we would be at any greater risk [from pharmaceuticals].

Healy's book must be read by anyone concerned about the development,

marketing and use of pharmaceutical drugs, particularly those drugs

prescribed for psychological conditions. Its portrayal, by an industry

insider, of a completely corrupt system that seems most concerned about

keeping pills flowing steadily out of factories, is deeply disturbing.

My biggest criticism of the book is that at times it becomes confusing, and

Healy does have a tendency to repeat himself. Although this means that the

book is not as accessible as it could be the extra effort expended is well

rewarded, and the book is well referenced and indexed, making it a valuable

addition to any personal or institutional medical library. There are

probably places where readers will find Healy drawing bizarre conclusions,

but these are generally on side issues. In the main, readers who are not

bought and paid for by the drug companies, will probably find themselves

drawn to the same depressing conclusions. Just be careful about initiating

drug therapy for any depression that does result!

Recent developments add strength to Healy's arguments. The UK regulator MHRA

(Medicines and Healthcare products Regulatory Agency ) warned late in 2003

about the use of SSRI anti-depressants for teenagers (with the exception

of Prozac!), because of the risk of suicide.[MHRA, 2003] Canada followed

suit with a warning about all SSRIs, including Prozac, and NSRIs (Serotonin

Noradrenaline Re-uptake Inhibitors ) as well.[Health Canada, 2004] Neither

country had ever approved this usage of the drugs, and neither country has

now banned this usage. Furthermore, they emphasize that nobody should stop

the drugs without consulting their physician. Both regulators also warn

about withdrawal symptoms, an admission that the drugs cause physical

dependency. Their message is based on one recent study, ignores older

research, and is still at variance with Healy's message that the drugs are a

risk no matter the age of the patient and that doctors are not a reliable

source of unbiased information.

It is quite possible that the days of these drugs are numbered, but even

their demise might not result in deep questioning about the sanity of using

any drugs for mild depression.

Further Reading

[FDA, 2004]

[Health Canada, 2004]

[Healy, 2003] Healy D. Let them eat Prozac. Lorimer. 2003.

[MHRA, 2003]

[schafer, 2003] Schafer A. Biomedical conflicts of interest: a

defence of the sequestration thesis: Learning from the cases of

Olivieri and Healy. JME. 2003; 28(2).