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Let Them Eat ProzacReview - Let Them Eat Prozac
The Unhealthy Relationship Between the Pharmaceutical Industry and Depression
by David Healy
New York University Press, 2004
Review by Jennifer Hansen, Ph.D.
Jul 26th 2005 (Volume 9, Issue 30)

The best way to read Let Them Eat Prozac is to first consider the events surrounding Healy's writing of the book.  He reports to us that he wrote this book and The Creation of Psychopharmacology (2002) during 2000 (2004, 286).  The year 2000 turns out to be a pivotal year in Healy's career because of two separate scrapes with what becomes the focus of Let Them Eat Prozac: conflicts of interest between the pharmaceutical industry and academia. 

The David Healy Affair

First, in late November 2000, Healy travels to the University of Toronto's Department of Psychiatry who invites him to speak for its seventy-fifth anniversary meeting, entitled "Looking Back: Looking Ahead." A year before this trip, The Center for Addiction and Mental Health (CAMH) has hired Healy as a professor of psychiatry in the Mood and Anxiety Disorders Program.  Healy has not yet made the move to Canada because he was waiting on his visa.  Healy delivers a talk entitled: "Psychopharmacology and the Government," which is basically an outline of The Creation of Psychopharmacology along with the assertion that SSRIs could make people suicidal.  This last point is, as I will explain below, the occasion for which Healy pens Let Them Eat Prozac.  The chief physician at CAMH, David Goldbloom, hears Healy's talk and reacts quite strongly to the content, particularly--to his mind--the irresponsible and unscientific suggestion that SSRI drugs can lead to suicidality in patients.  Shortly after an uncomfortable exchange with Goldbloom, Healy learns via email from Goldbloom that CAMH has decided to withdraw the offer to of a position as Clinical Director of the Mood and Anxiety Disorders program.  Healy describes, briefly, these events in chapter 9, "The Plot Thickens" (215-219), however, website dedicated to exposing these events (http://www.pharmapolitics.com) makes public the email exchanges between Goldbloom and Healy, Healy's talk, and subsequent letters written between various players in the scandal that follows. 

I strongly recommend reading through these documents before delving into Let Them Eat Prozac (even though Healy wrote most of the book before this took place).  Reading these documents brought to life, more powerfully than the events narrated in the book, the dangerous position that folks like Healy may be in regarding academic freedom now that mega pharmaceutical corporations, like Eli Lilly and Co., fund department research at places such as the CAMH at the University of Toronto.  At the time Healy delivers his talk, the Mood Disorders Program receives over 50 percent of its funding from pharmaceutical companies (2004, 215).  While the reasons why Goldbloom rescinds his offer to Healy may never be fully known, Healy points out that fear of losing precious and necessary funding from Eli Lilly and Co. for research may, in fact, be a contributing factor.

The second threat to Healy's academic freedom follows an article that Healy publishes, entitled "Good Science or Good Business?", in the March/April issue of The Hasting Center Report, which is a bioethics journal.  In this issue, Healy writes

Possibly, Prozac's success has also depended partly on a lack of information . . .Current methods to estimate the side effects of drugs in clinical trials actually underestimate them . . .the SSRIs have been sold on the back of a claim that the rate of suicide is 600 per every 100,000 patient years.  But this is the rate for people with severe depression, for which Prozac does not work.  The rate for primary care depression is on the order of 30 out of every 100,000 people.  Yet in these populations, suicide rates of 189 for every 100,000 on Prozac have been reported.  Thus there are good grounds to believe that Prozac can trigger suicidality.  The pharmaceutical companies are not investigating, however; one wonders whether they are receiving legal advice echoing that given to the tobacco companies, that any investigation of these issues may increase product liability" (2000, 21, my emphasis).

Soon after publication of this article, Eli Lilly and Co. withdraws what constituted a substantial donor gift to the Hastings Center, citing Healy's "unscientific" claim above as the reason.  Hence, the writing of Let Them Eat Prozac is mired in disquieting examples of exactly what Healy warns is discrediting the science of psychopharmacology: the need for Big Pharma to make profits for its shareholders is more pressing that the need for good science. 

Good Science or Good Business?

Let Them Eat Prozac is Healy's careful and, at times, tedious account of the discovery of SSRIs and the events that lead to the unprecedented marketing and prescribing of these drugs.  Healy is a first class scholar, supplying the reader with all available facts, figures and names of major players in this episode of psychopharmacology.  To an outsider to the field, keeping track of all the major names and dates in this history can be challenging.  Healy assiduously cites every possible scientific and factual claim he makes in the book, which requires a great deal of flipping back and forth to the comprehensive footnotes and bibliography.  However, when I realized the stakes in the writing of this book, reflecting on the Hastings Center, CAMH scandals and the three trials against Big Pharma that Healy chronicles, it became a lot clearer why Healy takes such pains to tell this story as completely and rigorously as possible.

Healy begins the book by giving a brief overview of the major changes occurring in psychiatry at the time that Prozac is first discovered.  What is notable in these chapters is Healy's claim that the downfall of Valium and other benzodiazepines in popular culture--due to claims that it was addictive--coincide with a growing awareness that severe depression and bipolar disorder is largely undetected and untreated.  Moreover, the conceptual framework of psychiatry shifts away from the language of neuroses and anxiety, towards biological psychiatric paradigms that conceive of mental disorders in terms of neurochemistry.  The vacuum created by the public dismissal of Valium then becomes filled by SSRIs, such as Prozac.  Rather than treat "nerves" or anxiety disorders, psychiatrists shift their attention to depression and its biological mechanism (which the public wrongly assumes is low serotonin levels [264]).  Pharmaceutical companies quickly see a new market opening up for SSRIs, in part because the drugs purportedly are more tolerable and patients could not overdose on these drugs.  The further you get into Let Them Eat Prozac, however, the sooner you will be disabused of the belief that SSRIs are relatively safe.

The current pervasiveness and popularity of the Prozac (and its SSRI cousins) for treating depression is particularly remarkable because early clinical trials suggest that it is not effective in treating severe depression, but rather for treating milder or subclinical depressions (something to which Peter Kramer's book Listening to Prozac is a testament) (32).  What also emerge early on in the clinical trials of Prozac and in clinical practice is a concern that it causes akathisia (agitated states) (14-15). Shortly after Prozac is released, in 1990, Martin Teicher, Carol Gold and Jonathan Cole publish an article in the American Journal of Psychiatry that suggests Prozac induces suicidality in patients (42-45).  Eli Lilly quickly moves to discredit this study because it is conducted in a center that specialize in suicidal patients, thus beginning the now familiar retort to the claim that Prozac induces suicidality:  it's the disease, not the drug (see 59).

Healy dedicates the rest of the book to cast doubt on this simple retort.  He details three court cases against Big Pharma: Fentress et al. vs. Eli Lilly, Forsyth v. Eli Lilly, Tobin v. SmithKline Beecham.  Each of these cases involves a suicide and/or homicide allegedly brought on by Prozac, or Zoloft in the Tobin case.  Eli Lilly wins the first two cases, but SmithKline Beecham loses the third case.  Healy is an expert witness in the Forsyth case and latter the Tobin case, which incidentally is pending during the whole "affair" at the University of Toronto.  Healy inform how the lawyers for SmithKline Beecham could use this "scandal" to discredit Healy's testimony, thereby weakening Tobin's case.  The details of these cases are quite interesting as well as profoundly sad.  Healy reports on these cases to illustrate how messy and dangerous the overlapping of Big Pharma, academics, physicians, and the FDA are:

One of the many chilling things about the Prozac story is that a mistake or conspiracy would probably have cost fewer lives.  Instead, a sequence of historical events made a poor drug fashionable, made the treatment of an illness all but a matter of public policy, and removed the natural cautions and safeguards that should have saved us.  In the midst of this, the one group with a professional brief, because of prescription-only arrangements, to save us from ourselves--physicians--appears to have followed its self-interest as much, if not more, than any other party to the story(251).

A rather interesting revelation in this book is that the Church of Scientology unwittingly contributes to lack of studies and information on how SSRIs may induce suicidality. Scientologists are a virulent strain of the "anti-psychiatrists." Their entire mission is to bring down psychiatry and strategically focus their campaign by protesting antidepressants and ADHD drugs (for an example, review the many news stories about Tom Cruise's campaign against antidepressants).  A 1990 Time article reports that Scientologists rely heavily on lawsuits to bring down psychiatrists and the pharmaceutical industries (59).  This ticks off psychiatrists who then unite behind Big Pharma. Relaying a conversation he has with an attorney involved in suits against Big Pharma, Healy writes: " . . . I launched into the influence of the Scientologists on the whole Prozac controversy.  If they hadn't intervened, U.S. psychiatry wouldn't have stood behind Lilly the way it had" (138).

Another troubling practice that Healy exposes is how deeply Big Pharma has penetrated academic journals and conferences. Apparently, Big Pharma hires writing agencies, such as Current Medical Directions (CMD) to write up:

studies, review articles, abstracts, journal supplements, product monographs, expert commentaries, and textbook chapters.  It conducts meta-analyses and organizes journal supplements, satellite symposia, consensus conferences, and even advisory boards for its clients.  In the course of 1998, CMD, on behalf of Pfizer, coordinated the authorship of approximately eighty-seven articles on Zoloft.  Of these, fifty-five were published by early 2001.  They targeted the leading journals in the field, including the New England Journal of Medicine (NEJM), JAMA, Archives of General Psychiatry, and The American Journal of Psychiatry, in addition to journals well known for the placement of psychopharmacology articles (116-117). 

For Healy, the real concern that "ghostwritten" articles pose is that the academics who allow their name to be put on the article often never see the original data from which conclusions were made; their judgment of the data is therefore skewed by what the pharmaceutical company chooses to report.  Big Pharma owns all data of from clinical trials and RCTs, hence scientists cannot easily get their hands on it to make independent judgments about the studies.

Healy reports his own experience with being approached to present at symposia wholly underwritten and organized by a pharmaceutical company as well as putting his name on a ghostwritten article (112-116).  The fact that Healy reveals his own participation in these practices is interesting, since it opens him up to charges of hypocrisy or complicity with the very market forces that he thinks are threatening academic freedom and good scientific research in psychopharmacology.  To me, these admissions reveal Healy's humanity.  Rather than resembling a "Socrates," whose pure dedication to morality seems far from our all-too-human natures, Healy shows us how easy it is to get involved with Big Pharma, to have them corrupt your own work, and the ugly side to all of this as well:  how publicly disagreeing or discrediting them can put your livelihood and reputation at stake.

Let Them Eat Prozac is a bold book and likely to draw a lot of criticism from fellow psychopharmacologists.  Moreover, the problems and questions that Healy raise seem far from any easy solutions, hence likely to make many readers--who might need psychopharmacological treatment--weary of trusting their physicians or the pharmaceutical industry.  While certainly Healy doesn't wish to wholly discredit his profession and carefully points out how hard it is to tell the good from the bad guys in this story, it is possible that the less careful or subtle readers of his book will make conclusions about psychiatry that will unfortunately resemble anti-psychiatrists or even Scientologists.  I hope, however, that those who undertake this book take the time to appreciate the balance and care that Healy takes to present this story.

 

Side note: A companion website to this Let Them Eat Prozac is located at http://www.healyprozac.com/

 

Works Cited

Healy, David.  2000.  "Good Science or Good Business?"  Hastings Center Report 30:19-22.

Healy, David.  2002.  The Creation of Psychopharmacology.  Cambridge, MA: Harvard University Press.

 

© 2005 Jennifer Hansen

 

Jennifer Hansen is an Associate Professor of Philosophy at Gettysburg College.  Her research focuses on feminist theory and the intersection of psychiatry and philosophy, with particular interest in affective disorders, such as depression. 


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