Next month, an advisory committee of the Food and Drug Administration will meet to discuss what might arguably be the most tendentious issue in modern psycho-pharmacology: the use of antidepressants to treat childhood and teen depression and the drugs' possible role in teen suicide. This comes on the heels of Britain having banned the prescribing of Paxil for children under 18 and advising against most other commonly prescribed antidepressants for that age group.
But the FDA should really be debating bigger issues, including the role these drugs have come to play in society, and the ways the drug companies have distorted the truth about their products.
The current crop of antidepressants, mostly selective serotonin reuptake inhibitors, or SSRIs, have become, in a sense, cultural products as well as medical products. We have embraced them as a society, yet we are intensely conflicted about them. They are not just pills but stories we tell ourselves about how we should feel and how life should be lived -- pills as movies if you will. This may well be the reason we have such mixed feelings about antidepressants: We simply don't know how to assess them objectively, independent from the tales we have told ourselves.
One reason for that is the speed with which these drugs were launched out of the corporate womb and into the patient population. In the old days, before medicines were marketed directly to consumers, prescription drugs took years to gain a foothold and hence become profitable. Doctors stuck to the tried and true and were slow to embrace new drugs. But after Congress passed a law in the 1980s making generic drugs easier to get, brand-name companies had to become entrepreneurial; they realized they could no longer afford long waits for profitability.
This change led directly to a whole new marketing strategy at the big pharmaceutical companies: Rather than marketing to the relatively small pool of potential prescribers with psychiatric training, they cast a wider net: focusing on building demand among general practitioners -- and later, more directly, among patients themselves. To help general practitioners unfamiliar with antidepressants explain the drugs to their patients, the manufacturers created easily understood stories, maintaining that SSRIs, such as Prozac (made by Lilly), Paxil (GlaxoSmithKline) and Zoloft (Pfizer), were not like the previous generations of psych meds. They were not uppers or downers or tranquilizers that turned patients into zombies but more sophisticated compounds that simply reestablished our "natural" neurotransmitter balance. It was a powerful message to a generation of patients inclined toward the natural.
The balance story is not exactly a lie, but it's not exactly the truth, either. When pushed, in a lawsuit against his company, Alan Metz, vice president for clinical development at Glaxo, admitted in court papers, "It's not possible really to measure total serotonin." He added that "we do not know with absolute certainty about how any of the antidepressants work." If the drug companies can't really measure what normal serotonin levels are, and they don't know really how the drugs work, then how can we say they restore balance?
A more accurate version of the message would be this: Varying levels of various neurotransmitters, including serotonin, are associated with varying levels of depression. But that doesn't make as good a story, and so the industry has aggressively and successfully promoted the notion of neuro-balance. SmithKline, before its merger with Glaxo, explained Paxil's effects with animations of a pool table, on which balls ricocheted madly until they were put back in order by Paxil. Pfizer, the largest pharmaceutical company in the world, sponsors "Brain: The World Inside Your Head," a traveling show for science museums in which the company tells children that depression may be caused by, you guessed it, "an imbalance in neurotransmitters."
So does this mean that the big pharmaceutical companies are evil, as the Church of Scientology and other conspiracy buffs have suggested? Of course not. It simply means that Pfizer, Glaxo, Lilly and the rest are doing what they are supposed to do: make money. If they have gained in recent years far too much cultural power, it is because we have given it to them.
Are the drugs evil? Again, not at all. They are, at least in the short run, quite valuable, if monitored closely. Even the foremost critic of SSRI overuse, the British specialist David Healy, still prescribes antidepressants other than Paxil to patients.
The chief myth is that SSRIs -- being restorers of "natural" balance -- are safer than previous generations of psychiatric meds and, therefore, OK for family doctors to prescribe. They are not necessarily safer, and they should be prescribed only by people trained in their use who will closely monitor patients.