Book Review
Psychopharmacology
Let Them Eat Prozac. David Healy. Toronto: James Lorimer & Company Ltd; 2003. 462 p. CAN$29.95.
Reviewer
rating*: Very Good
Review by: Dorian Deshauer, MD
Ottawa, Ontario
Freedom to innovate and make profits does not necessarily go hand-in-hand with socially responsible actions. This theme is one of the central issues of our time and resonates throughout David Healy’s latest book. The bottom line? Biased study designs, publication bias, and outright misrepresentation may cloud the quest for truth and the public interest, particularly when science and big business get together. What standards are reasonable to expect of regulatory bodies, pharmaceutical companies, and physicians? Somewhere between a le Carre spy novel and Ivan Illich’s Medical Nemesis, Healy seems to have been everywhere at once in the clubby atmosphere of antidepressant development.
Prozac has become a cultural icon and may, at times, lead to more harm than the public is generally aware of, according to Healy. Mass marketing of serotonergic antidepressants, in general, has broadened the definition of depression to the extent that people could confuse melancholic depression with milder forms of depression and anxiety presumably seen in doctor’s offices. These milder forms of depression are what people once received valium for, not electroconvulsive therapy. Healy says these milder forms of depression, when left alone, also come with a lower suicide rate than expected among more severe cases—a rate approximating the general population risk. Prozac, he claims, may confer additional suicide risk in this group, owing in part to an agitation that sets in during the first weeks of treatment. That Prozac (and other selective serotonin reuptake inhibitors [SSRIs]) can agitate persons who are already feeling anxious and down is not news, but a compiled body of evidence, including a small study of normal volunteers, a rereading of existing databases, and a synthesis taken from mountains of courtroom proceedings, makes for interesting reading. Further, the increased suicidal thinking apparently caused by Prozac may occur more commonly than it does with other drugs of the same class, perhaps at triple the rate. This point is rather sticky and has received international press including articles in the Guardian, The Economist, and other major publications. A recent Canadian version is published as a debate between Dr Healy, who makes the case for SSRI-induced suicide, and Dr Lapierre, who reviews the available data and concludes that there is insufficient evidence to reject a null hypothesis of no increased suicide risk owing to SSRIs. The debate is available online, free of charge (1,2; links are available through PubMed or www.cma.ca.
What sort of medical establishment emerges when individual duty and obligation have been overshadowed by accountability—a subtle but important shift to a medical world governed by the courts and by powerful lobby groups? This subtext permeates a discussion of how establishing causal associations in medicine has moved away from studies that use a challenge, dechallenge, and rechallenge design toward those using large multicentred, hugely expensive, randomized clinical trials. While carefully conducted randomized trials are critical in sorting out small effects, they have, on account of sheer complexity and cost, put drug development and testing directly into the private sector. Such a concentration of knowledge and data among an elite few has led to proprietary databases and, in turn, to the selective release of information. Science relies on multiple experiments and cross-validation before information is accepted into its main body of knowledge. In the case of widespread SSRI use, this process is still in play. The laboratory, however, has now expanded to include society at large, particularly with direct-to-consumer marketing and industry’s dominance in physician education. But there is a more sinister tone to this book—one that moves us into the realm of a spy novel—which questions the integrity of those in power, of representatives in the food and drug administration, the press, and even the judiciary. While Healy stops short of pointing fingers, he has personally laid down the gauntlet without the shield of fiction behind which other writers and social critics can find protection.
“Within medicine, the physician is supposed to be the consumer watchdog” (p 87). Perhaps in addition to primum non nocere (above all, do no harm), physicians should add caveat emptor to their oaths. Perhaps medicine’s icons, after Hippocrates, will become consumer advocates. As historians of medicine have pointed out, the field tends to go through periods of recalibration, reflecting both technological and political shifts. With improved understanding of psychiatric disorders, their transmission within families, and their determinants within the general population, psychiatry is likely to reinterpret its role in society. Will it pursue a course guided by duty and obligation to patients, or will it be shaped primarily by courtroom standards? Will the field be dominated by private interests, or will there be a credible and independent counterpart to mount a debate in a system where few answers, if any, are cut and dried?
References
1. Healy D, Whitaker C. Antidepressants and suicide: risk-benefit conundrums. J Psychiatry Neurosci 2003;28:331–7.
2. Lapierre Y. Suicidality with selective serotonin reuptake inhibitors: valid claim? J Psychiatry Neurosci 2003;28:340–7.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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