During the summer of 2002, The Oprah Winfrey Show was graced by a visit from Ricky Williams, the Heisman Trophy holder and running back extraordinaire of the Miami Dolphins. Williams was there to confess that he suffered from painful and chronic shyness. Oprah and her audience were, of course, sympathetic. If Williams, who had been anything but shy on the football field, was in private a wilting violet, how many anonymous citizens would say the same if they could only overcome their inhibition long enough to do so?
To expose one’s shyness to what Thoreau once called the broad, flapping American ear would itself count, one might think, as disproof of its actual sway over oneself. But football fans knew that Ricky Williams was no voluble Joe Namath. Nevertheless, there he was before the cameras, evidently risking an anxiety attack for the greater good—namely, the cause of encouraging fellow sufferers from shyness to come out of the closet, seek one another’s support, and muster hope that a cure for their disability might soon be found.
Little of what we see on television, however, is quite what it seems. Williams had an incentive—the usual one in our republic, money—for overmastering his bashfulness on that occasion. The pharmaceutical corporation GlaxoSmithKline (GSK), through its public relations firm, Cohn & Wolfe, was paying him a still undisclosed sum, not to tout its antidepressant Paxil but simply to declare, to both Oprah and the press, “I’ve always been a shy person.”
To understand why this was considered a worthwhile outlay, we need to know that the drug makers earn their enormous profits from a very few market-leading products for which new applications are continually sought. If those uses don’t turn up through experimentation or serendipity, they can be conjured by means of “condition branding”—that is, coaching the masses to believe that one of their usual if stressful states actually partakes of a disorder requiring medication. A closely related term is more poetical: “astroturfing,” or the priming of a faux-grassroots movement from which a spontaneous-looking demand for the company’s miracle cure will emanate.
In this instance Cohn & Wolfe, whose other clients have included Coca-Cola, Chevron Texaco, and Taco Bell, was using an athlete to help create a belief that shyness, a common trait that some societies associate with good manners and virtue, constitutes a deplorably neglected illness. Given the altruistic aura of the occasion, it would have been tasteless to have Ricky Williams display a vial of Paxil on the spot. But later (before he was suspended from the football league for ingesting quite different drugs), a GSK press release placed his name beneath this boilerplate declaration:
As someone who has suffered from social anxiety disorder, I am so happy that new treatment options, like Paxil CR, are available today to help people with this condition.
There is nothing out of the ordinary in this episode, but that is just why it bears mentioning. Most of us naively regard mental disturbances, like physical ones, as timeless realities that our doctors address according to up-to-date research, employing medicines whose appropriateness and safety have been tested and approved by a benignly vigilant government. Here, however, we catch a glimpse of a different world in which convictions, perceived needs, and choices regarding health care are manufactured along with the products that will match them.
The corporate giants popularly known as Big Pharma spend annually, worldwide, some $25 billion on marketing, and they employ more Washington lobbyists than there are legislators. Their power, in relation to all of the forces that might oppose their will, is so disproportionately huge that they can dictate how they are to be (lightly) regulated, shape much of the medical research agenda, spin the findings in their favor, conceal incriminating data, co-opt their potential critics, and insidiously colonize both our doctors’ minds and our own.
If we hear, for example, that an unprecedented epidemic of depression and anxiety has recently been sweeping the world, we tend not to ask ourselves whose interest is served by that impression. In their painstaking study The Loss of Sadness, Allan V. Horwitz and Jerome C. Wakefield cite the World Health Organization’s projection
that by 2020 depression will become the second leading cause of worldwide disability, behind only heart disease, and that depression is already the single leading cause of disability for people in midlife and for women of all ages.
The WHO also ranks depression, in its degree of severity for individual victims, ahead of “Down syndrome, deafness, below-the-knee amputation, and angina.” But Horwitz and Wakefield cogently argue that those judgments rest on a failure to distinguish properly between major depression, which is indeed devastating for its sufferers, and lesser episodes of sadness. If so, the WHO would appear to have bought Big Pharma’s line of goods.
This isn’t to say that people who experience infrequent minor depression without long-term dysfunction aren’t sick enough to deserve treatment. Of course they are. But as all three of the books under consideration here attest, the pharmaceutical companies haven’t so much answered a need as turbocharged it. And because self-reporting is the only means by which nonpsychotic mental ailments come to notice, a wave of induced panic may wildly inflate the epidemiological numbers, which will then drive the funding of public health campaigns to combat the chosen affliction.
This dynamic also applies to a variety of commonplace if bothersome states that the drug makers want us to regard as chemically reparable. They range from excitability and poor concentration to menstrual and menopausal effects and “female sexual dysfunction,” whose signature is frustration in bed with the presumably blameless husband or lover. And the same tactic—exaggerate the problem but imply that medication will easily fix it—plays upon legitimate worries over cardiovascular disease, osteoporosis, irritable bowel syndrome, and other threats.1 As patients on a prophylactic regimen, we are grateful for any risk reduction, however minuscule; but our gratitude leaves us disinclined to ask whether the progressively lowered thresholds for intervention were set without any commercial influence. In that sense our prescribed drugs do extra duty as political sedatives.
Clearly, the drug companies’ publicists couldn’t exercise their consciousness-shaping wiles so fruitfully without a prior disposition among the populace to strive for self-improvement through every legal means. (Neither GlaxoSmithKline nor Cohn & Wolfe invented The Oprah Winfrey Show.) For the past half-century, first with tranquilizers like Miltown and Valium and more recently with the “selective serotonin reuptake inhibitors” (SSRIs), Americans have required little prodding to believe that a medication can neutralize their social handicaps and supply them with a better personality than the one they were dealt by an inconsiderate fate. The vintage and recent advertisements reproduced in Christopher Lane’s polemical Shyness, which features the manipulations that promoted social anxiety disorder to a national emergency, reflect Madison Avenue’s grasp of this yearning to be born again without the nuisance of subscribing to a creed.
Hopes along those lines for Valium and its cousins were soon dashed; the drugs did serve as calmants but at the cost of eventually producing mental fogginess and dependency. In the 1990s, however, the SSRIs Prozac, Zoloft, Paxil, Luvox, Celexa, and Efexor seemed very different, enhancing alertness and making many users feel as if a better self were surfacing. Peter Kramer, without ironic intent, named this phenomenon “cosmetic psychopharmacology,” and his best-seller Listening to Prozac (1993) swelled a utopian wave that was racing ahead of the drug companies’ most optimistic projections.
Even Kramer, though, felt obliged to mention certain troubling effects of Prozac that were already coming to light in the early Nineties. These included, for some users, uncontrollable tremors, diminished sexual capacity, a growing tolerance that was leading to potentially noxious higher doses, and “suicidality,” or self-destructive tendencies cropping up in the early weeks of treatment. But because Kramer’s readers were weighing the risks not against a discrete medical benefit but against the prospect of becoming self-assured and gregarious at last, those cautions were generally disregarded.
This point is acknowledged in Kramer’s recent book Against Depression (2005)—which, however, outdoes even the World Health Organization in its awe before the galloping plague (“The most disabling illness! The costliest!”). Kramer may want to believe the worst about depression’s ravages so that the SSRIs he once hailed will still be considered a net boon. Perhaps they are such; I am in no position to judge.2 But one thing is certain: the antidepressant makers have exploited our gullibility, obfuscated known risks, and treated the victims of their recklessness with contempt. That history needs to be widely known, because the same bullying methods will surely be deployed again as soon as the next family of glamour drugs comes onstream.
Hence the importance of David Healy’s stirring firsthand account of the SSRI wars, Let Them Eat Prozac. Healy is a distinguished research and practicing psychiatrist, university professor, frequent expert witness, former secretary of the British Association for Psychopharmacology, and author of three books in the field. Instead of shrinking from commercial involvement, he has consulted for, run clinical trials for, and at times even testified for most of the major drug firms. But when he pressed for answers to awkward questions about side effects, he personally felt Big Pharma’s power to bring about a closing of ranks against troublemakers. That experience among others has left him well prepared to puncture any illusions about the companies’ benevolence or scruples.
Healy doesn’t deny that SSRIs can be effective against mood disorders, and he has prescribed them to his own patients. As a psychopharmacologist, however, he saw from the outset that the drug firms were pushing a simplistic “biobabble” myth whereby depression supposedly results straightforwardly from a shortfall of the neurotransmitter serotonin in the brain. No such causation has been established, and the proposal is no more reasonable than claiming that headaches arise from aspirin deprivation.3 But by insistently urging this idea upon physicians and the public, Big Pharma widened its net for recruiting patients, who could be counted upon to reason as follows: “I feel bad; I must lack serotonin in my brain; these serotonin-boosting pills will surely do the trick.”4 Thus millions of people who might have needed only counseling were exposed to incompletely explained risks.
Those risks, Healy perceived, included horrific withdrawal symptoms, such as dizziness, anxiety, nightmares, nausea, and constant agitation, that were frightening some users out of ever terminating their regimen—an especially bitter outcome in view of the manufacturers’ promise of enhancing self-sufficiency and peace of mind. The key proclaimed advantage of the new serotonin drugs over the early tranquilizers, freedom from dependency, was simply false. Moreover, the companies had to have known they were gambling wildly with public health. As early as 1984, Healy reports, Eli Lilly had in hand the conclusion pronounced by Germany’s ministry of health in denying a license to fluoxetine (later Prozac): “Considering the benefit and the risk, we think this preparation totally unsuitable for the treatment of depression.”
These matters are discussed in Ray Moynihan and Alan Cassels's Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All into Patients (Nation Books, 2005), which also cites the Ricky Williams story.↩
For recently unearthed considerations bearing on the prudent use of these drugs, see Robert D. Gibbons et al., "Early Evidence on the Effects of Regulators' Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adults," American Journal of Psychiatry, Vol. 164, No. 9 (September 2007), pp. 1356–1363, and Gonzalo Laje et al., "Genetic Markers of Suicidal Ideation Emerging During Citalopram Treatment of Major Depression," American Journal of Psychiatry, Vol. 164, No. 10 (October 2007), pp. 1530– 1538.↩
The serotonin etiology of depression is concisely disputed in Horwitz and Wakefield's The Loss of Sadness, pp. 168–170. See also Elliot S. Valenstein, Blaming the Brain: The Truth About Drugs and Mental Health (Free Press, 1998), and Joseph Glenmullen, Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Anti-depressants with Safe, Effective Alternatives (Simon and Schuster, 2000).↩
Healy cites Tipper Gore in 1999: "It was definitely a clinical depression.... What I learned about it is your brain needs a certain amount of serotonin and when you run out of that, it's like running out of gas." Contrary to industry propaganda, the brain possesses no known "depression center," and about 95 percent of our serotonin is found elsewhere in the body. By raising serotonin levels, the SSRIs interfere with production of the other natural "feel-good" chemicals, adrenaline and dopamine. In that sense they are hardly as "selective" as we have been led to believe.↩
These matters are discussed in Ray Moynihan and Alan Cassels’s Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All into Patients (Nation Books, 2005), which also cites the Ricky Williams story.↩
For recently unearthed considerations bearing on the prudent use of these drugs, see Robert D. Gibbons et al., “Early Evidence on the Effects of Regulators’ Suicidality Warnings on SSRI Prescriptions and Suicide in Children and Adults,” American Journal of Psychiatry, Vol. 164, No. 9 (September 2007), pp. 1356–1363, and Gonzalo Laje et al., “Genetic Markers of Suicidal Ideation Emerging During Citalopram Treatment of Major Depression,” American Journal of Psychiatry, Vol. 164, No. 10 (October 2007), pp. 1530– 1538.↩
The serotonin etiology of depression is concisely disputed in Horwitz and Wakefield’s The Loss of Sadness, pp. 168–170. See also Elliot S. Valenstein, Blaming the Brain: The Truth About Drugs and Mental Health (Free Press, 1998), and Joseph Glenmullen, Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Anti-depressants with Safe, Effective Alternatives (Simon and Schuster, 2000).↩
Healy cites Tipper Gore in 1999: “It was definitely a clinical depression…. What I learned about it is your brain needs a certain amount of serotonin and when you run out of that, it’s like running out of gas.” Contrary to industry propaganda, the brain possesses no known “depression center,” and about 95 percent of our serotonin is found elsewhere in the body. By raising serotonin levels, the SSRIs interfere with production of the other natural “feel-good” chemicals, adrenaline and dopamine. In that sense they are hardly as “selective” as we have been led to believe.↩