In the years following the release of Prozac in 1988, the pharmaceutical industry fractured into ever deeper warring fragments. The ensuing battle concerned what company would gain the greatest share of a rapidly emerging market opportunity: the demand for a brand-new wave of antidepressants believed far superior to earlier psychiatric drugs. This market would be worth billons of dollars annually to any company able to convince doctors and the wider public that it manufactured the most efficacious pill. As company after company charged in to win its market share, different versions of this new antidepressant arrived year on year—Prozac, Effexor, Seroxat, Lustral, Cipramil—each claiming to be better than the last.
Given the vast amounts of money at stake, it is little surprise that companies developed increasingly sophisticated marketing techniques to persuade people that their drugs worked best. In places like Britain, where the pharmaceutical industry was prohibited from directly advertising its pills to the public, it had to rely solely on what is generally called physician-directed marketing. This meant that GPs, psychiatrists, academic researchers, and psychiatric nurses all became targets of elaborate promotional exercises by which the profile of a particular drug could be raised and the number of prescriptions increased.
The seriousness with which companies took these marketing offensives is illustrated by the vast amounts of money they spent. At the height of the marketing war, the industry invested twice as much money in promoting its pills as it did in researching and developing them. For instance, in the mid-2000s companies were spending $2.52 billion on drug promotion in Britain each year. This investment is evidenced by how quickly marketing departments in the pharmaceutical companies expanded. The ex-editor of the British Medical Journal stated, for example, that between 1995 and 2004 there may have been a 59 percent increase in the number of employees working pill promotion, while jobs were actually cut in drug research.133 Because a large proportion of these vast resources were used in promoting antidepressants, it’s safe to say that during the 1990s and 2000s the British public’s escalating familiarity with these drugs was largely a product of the pharmaceutical marketing machine.
What kinds of strategies did companies use to promote their pills so successfully? In what kinds of tactics did they so heavily invest to achieve their financial goals? How did the pharmaceutical industry, in other words, manage to transform an obscure set of SSRI antidepressants in the early 1990s, which really didn’t work too well and were dangerous in many ways, into one of the most widely prescribed species of drug in medicine today?
2
In early 2001 Daniel Carlat, like thousands of other psychiatrists at the time, became embroiled in this drug marketing war.134 The particular battle in which he got tied up concerned a new antidepressant called Effexor, developed by the pharmaceutical company Wyeth. During the early 2000s, the company was on a promotional offensive to convince practitioners across Europe and the United States that Effexor was superior to its competitors. Unlike the existing SSRI antidepressants, which just targeted serotonin levels, Effexor was rather a “dual reuptake inhibitor,” which meant it targeted two neurotransmitters (serotonin and norepinephrine). Wyeth claimed that Effexor’s dual action rendered it superior to its SSRI-only competitors. And so this was the message Wyeth reps sold wherever they entered doctor’s offices whether in Birmingham, Nottingham, Manchester, or London; in Washington, Boston, Philadelphia, or New York, the sales reps worked the same simple objective: convince doctors you visit that Effexor is the best.
On a nondescript afternoon in 2001, one of these sales reps would confidently stride into Dr. Daniel Carlat’s office with an enticing offer in hand. Would Carlat be willing to give some talks about Effexor to other doctors? Sure, he’d be paid for the talks (between $500 and $750 per hour), and sure, he’d receive some training. But the training really wouldn’t take long—and he’d be paid for that too. All he needed to do was turn up at a hotel in New York in a few weeks’ time and attend a two-day crash course on Effexor. Then he’d be ready. His stay would also be very comfortable—all expenses paid, of course. What’s more, he needn’t leave his wife at home. Her ticket was paid for too.
“I was extremely flattered by this offer,” Carlat confessed to me as he recounted the drug rep’s visit, “especially since I’d been out of the academic setting for so long working in a small community.” Indeed, since finishing his psychiatry residency a few years earlier, Carlat’s career had remained decently modest. “I’d been working half-time in an inpatient unit and half-time in my own private practice,” said Carlat. “I was just spending my time enjoying meeting patients and learning my craft.”
Carlat enjoyed no glitzy pharmaceutical links or perks even though he knew lots of other psychiatrists had been enticed by them, something he first noticed when still training as a psychiatrist at medical school. “I realized back then there were a lot of doctors and academics who were doing work with pharmaceutical companies, either doing research or just jetting around the country or even the world, giving different kinds of presentations. Their lifestyle appeared very glamorous. And there was an unspoken sense among the psychiatry trainees that this was the lifestyle to one day chase after too.”
Perhaps a seed had been sown back then, because a few weeks after the Wyeth rep stepped into Carlat’s office, Carlat and his wife would step off the plane in New York. They would then make their way to a luxurious hotel in the heart of Manhattan, where a Wyeth attendant with a dazzling smile would greet them. She would hand Carlat a conference pack containing a schedule of talks as well as invitations to various dinners and receptions and, surprisingly, two tickets for a Broadway musical. Despite the pang of conscience Carlat felt at having so much money lavished on him, he couldn’t help but feel, well, kind of special. How very distant his small-town practice now suddenly seemed from the glamorous world into which he had been invited.
In between the various dinners and entertainment events, Carlat eagerly attended the talks, which were delivered by some leading lights in antidepressant research. First, there was Dr. Michael Thase from the University of Pittsburgh. He was the global authority on Effexor and one of the most respected psychiatrists in the United States. Thase’s task was to report the findings of his huge meta-analysis, which included studies covering more than two thousand patients. Thase’s results were so impressive that Carlat soon understood why they were taking the world of psychiatry by storm.
Effexor achieved a remarkable 45 percent remission rate, which in layperson’s terms meant that 45 percent of patients experienced a complete disappearance of symptoms. With results like these, Effexor far excelled the existing SSRIs (whose remission rate was only 35 percent) and placebos (remission rate 25 percent). If these figures held true, then for the first time in modern psychiatry one antidepressant stood out from all the rest. Not only would this revolutionize what doctors would prescribe, but it would also increase Wyeth’s profits by literally billions of dollars a year. Could Thase’s results be trusted?
Thase was determined they could. And to prove this he would spell out carefully to the crowded room of psychiatrists the main objections to his research so he could impressively rebut each in turn. The first objection he addressed was that Wyeth had funded his meta-analysis. Did this not create a conflict of interest that may have potentially biased his study? Thase was sanctimonious. He and his team had consulted all the data and not cherry-picked the results most favorable. They had abided by the strictest scientific standards, ensuring that their objectivity could not be purchased. It was as simple as that.
Another objection was that Effexor had only been compared to one SSRI—Prozac. So presumably other SSRIs may perform better. Thase was ready for that one, too. Since the original study, he had analyzed data about Paxil and other SSRIs. And as luck would have it, these also showed similar advantages for Effexor. Case closed.
The final objection concerned why Thase had chosen to measure “remission” rates over the more usual “response” rates. The difference was subtle but important. For instance, a “response” is achieved when a patient experiences a 50 percent improvement on the Hamilton Scale (e.g., moving from 30 points before treatment to 15 points after treatment), while “remission” is defined as complete recovery (in Thase’s study this meant achieving a score of 7 or below on the Hamilton Scale). Had Thase chosen to measure remission over response because it would make Effexor look superior? Carlat couldn’t work it out until Thase addressed the issue head on: no matter where you put the cut-off rate for remission (7 points, 6 points, 9 points, etc.) Effexor always came out on top. With each rebuttal the audience grew more convinced.
After Thase received eager applause for this impressive display, the next speaker made his way to the podium: a psychiatrist called Norman Sussman, a professor at New York University. Sussman was a typical front man, more charismatic and personable than the lithe and academic Thase. He was also an expert popularizer, demonstrating fluently to the psychiatrists gathered the most effective manner in which they could communicate the great news about Effexor to doctors up and down the country.
And so the talks continued, until by the end of the weekend, the attendees had been thoroughly dosed with a mixture of genuine education and effective sales techniques. If any lingering doubts remained, well, there was no need to dwell on them now. The last night of the conference had arrived, and what’s more there was a surprise waiting: for Carlat it came in the form of a small envelope containing $750. “It was now time to enjoy the city,” as Carlat put it.135
When Carlat returned to his small practice in Newburyport, there were already two messages from Wyeth reps waiting on his answering machine. Obviously, the company wanted to begin its promotions in earnest. Carlat would deliver his talks once or twice a week during his lunch breaks. This time suited everyone, including the reps who could use the occasion to entice bigger audiences with offers of a free lunch. Sometimes there’d be just a small gathering of doctors and nurses, sometimes a crowded conference room, and at other times just Carlat and a single physician.
While each setting was different, one thing never changed. There was always a drug rep present, scrutinizing Carlat’s performance and occasionally giving him notes after a talk: emphasize this, don’t worry about that, enjoy yourself more, you’re doing well. Before his talks the reps would also advise Carlat about the prescription habits of the various doctors he’d be addressing that day. They obtained this crucial information from data-mining companies that accessed prescribing data recorded at pharmacies. These data were repackaged and sold to companies like Wyeth so they could tailor their sales strategies accordingly. The whole operation was very slick, and Carlat was beginning to feel uneasy.
He soon realized that his $500 to $750 an hour came at a price. “When I was sitting in New York, I could never have imagined the huge pressure I’d be under to perform in those talks in a certain way,” Carlat said to me. “When you are being paid a significant amount of money to promote a pill, and when you know that the reps are going to decide whether to invite you back depending on whether the doctors will prescribe Effexor after your talk, the question is how that pressure affects you. Does it cause you to highlight the advantages inappropriately and to downplay the side effects? Did the promise of more money actually affect the content of what I was telling those doctors? I struggled with those questions.”
The struggle deepened as Carlat began to encounter more criticisms of Effexor. New data seemed to show that the remission rates for the drug were far less impressive than Thase had reported in New York—more like 5 percent better than SSRIs instead of the reported 10 percent. Also, Carlat realized that Thase’s meta-analysis may have been a victim of some of the methodological games I discussed in chapter 8. For example, some patients enrolled in the original Effexor studies had taken SSRIs in the past and had presumably not responded well. This meant that the study population might have included patients who were already treatment-resistant to SSRIs, therefore giving Effexor an inherent advantage.
Finally, the majority of studies Thase assessed in his meta-analysis were fairly short-term—only six or eight weeks long—so there was a possibility that if the clinical trials had been longer (e.g., six months or a year), the response and remission rates of the SSRIs compared with Effexor’s would have turned out to be the same.
Although Carlat knew that this crucial information invited “the kinds of methodological discussion that may really be important for doctors to hear,” Carlat kept this highly relevant information out of his talks. He feared that if he mentioned it, the reps wouldn’t invite him back. But at the same time he also realized “by not mentioning them I was committing sins of omission.” Carlat began to struggle seriously with the ethics of his position—a struggle very soon deepened by two events.
The first occurred at a lunchtime meeting when Carlat was talking about Effexor to a group of psychiatrists. One psychiatrist took issue with Carlat’s view that high blood pressure was relatively uncommon with low doses of Effexor, stressing that in his clinical experience Effexor’s record on hypertension was pretty poor. Carlat was caught off guard and struggled to respond. Sure, back in New York Thase had actually briefly addressed the blood pressure problem. But Carlat was also aware that “while there are data to support the position that the drug is safe, when you really dig more deeply into the data, the full story isn’t quite as cut and dried.”
In other words, Carlat had been trained to talk about Effexor’s weakness in a way that would reflect best for the drug and encourage doctors to try it out. “This did not mean the company ever told us to deny these side effects exist,” said Carlat, “only that you just had to talk about the side effects to physicians in a way that wouldn’t alarm them. And you’d also have to couch them in a way that would convince doctors that Effexor was worth trying even before, in some cases, safer medications had already been tried.”
The disagreement forced Carlat to acknowledge that he was spinning the study’s results in the most positive way possible while playing down the limitations of the data. “I thought to myself,” said Carlat frankly, “that I’m ultimately doing more of a disservice by discussing the data in simplistic terms than I am serving these doctors in educating them about the drug.” His style had to change. He would have to be more upfront.
Then came the second event. “I decided in one talk to say that the studies of Effexor were very short, and that if they’d been longer it’s feasible that the competitors of Effexor may have caught up. But when I made that point in front of the doctors, the drug reps did not look very happy. The next day I had an unexpected visit from the district manager of Wyeth, who said the reps had told him that in my last talk I didn’t seem so enthusiastic about his product. He then looked at me closely and asked, ‘Have you been sick?’ I was shocked. It was as if the only possible way I could not be enthusiastic about his product was if I were somehow ill—not on my game.”
That encounter was decisive for Carlat. “It laid bare for me my role from the standpoint of the company, which was to be a marketer for their drug. And to the extent that I said anything that was in any way negative or not glowingly positive about their product, I was less and less useful to them, even if what I were saying was accurate. That was the tipping point when I decided to stop giving promotional talks.”
When I asked Carlat whether he believed his talks influenced the prescribing habits of the doctors he addressed, he was unequivocal. “I would be astonished if my talks did not significantly affect their prescribing behaviors. And the reason I say that is I was talking to primary care doctors and family practitioners who are not specialized in psychiatry. To them I was an expert simply educating them about the benefits of Effexor. So they just assumed, well, as he’s saying it, it must be true and I should try prescribing it.”136
This, indeed, was the intended effect. And if “Key Opinion Leaders” like Carlat didn’t achieve this effect, there would be tangible consequences. As Kimberly Elliott, who handled Key Opinion Leaders for a number of pharmaceutical companies, put it: “Key opinion leaders were salespeople for us, and we would routinely measure the return on our investment by rating prescriptions before and after their presentations.” She continued, “If that speaker didn’t make the impact the company was looking for, then you wouldn’t invite them back.”137
3
There are many startling things about the case of Dr. Carlat, most of which go without saying. But one strategy that I think is essential to how the pharmaceutical industry markets its pills does warrant mention. This involves exploiting the highly hierarchical nature of the medical profession, in which an almost caste-like system of professional rank arranges the relations between its various “orders.” Junior doctors defer to registrars, who defer to consultants, who in turn bow to their more senior consultants. This pyramid of ascending seniority sees each rank sitting atop and enjoying authority over the ranks below.
Companies therefore know that if they are to convert the pyramid’s base, they must first convert those at the top. They must recruit senior psychiatrists like Dr. Michael Thase and Dr. Norman Sussman to convince less senior doctors like Daniel Carlat to spread the message to the wider ranks of medical students, junior doctors, primary care physicians, and GPs.
This latter group is especially important because the vast majority of antidepressants are not actually prescribed by senior psychiatrists, or even by psychiatrists at all, but by family doctors and GPs who listen carefully to the advice psychiatrists provide.138 After all, your kindly and overworked local GP has little time to scrutinize all the research relevant to every drug that he or she daily prescribes, and so is reliant on what more senior people like Thase impart through medical journals and on what less senior doctors like Carlat impart during their visits.
This strategy of paying “Key Opinion Leaders” like Thase and Sussman to ensure that community preferences align as closely as possible with company interests sheds a bit of light on why Senator Grassley found so many senior psychiatrists receiving eye-popping amounts of industry money. An endorsement from a top researcher at a senior university will benefit your brand far more than a thousand company reps could ever do. This is especially the case if their endorsement is itself published in a journal of high repute, which has often led companies to brazen excesses to get the recruit journal support.
And I am not just talking about providing financial incentives for editors to publish company-sponsored research (chapter 8), or designing, conducting, and writing research to which academics then merely put their names (a practice known as ghost-writing), but about strategies that go even further: One recent case saw the drug giant Merck, for example, pay an undisclosed sum to the international academic publishing house Elsevier to produce several volumes of a publication that had the look of a peer-reviewed medical journal but actually only contained reprinted or summarized articles, most of which, unsurprisingly, presented data favorable to Merck products.139
While feeding the top of the food chain is a crucial company marketing strategy, this does not mean that the junior ranks are left alone. They are not only visited by pharma reps and by speakers like Carlat (albeit perhaps in fewer numbers than in Carlat’s day), but they too can be invited to all-expenses-paid conferences or “continuing medical education” events where experts discuss new treatments. They are also regularly sent free drug samples in the hope that their prescribing habits will alter, and are sometimes asked to find patients for drug trials while being offered strong financial inducements. At the same time, they are subjected to a barrage of adverts for psychiatric drugs placed in medical journals.140
Company marketing directives should therefore be a matter of serious concern for the general public, not least because it would be naïve to suppose that marketing campaigns have played no role in inflating prescriptions (the 46.7 million NHS antidepressant prescriptions in 2011 cost the British taxpayer over a quarter of a billion pounds last year).141 After all, if these marketing strategies did not work, you’d hardly expect pharmaceutical companies to keep investing in them.
4
While the prescribing figures in the UK are high, in the United States they are higher—not by much, mind you, only in fact by around 13.5 percent. To put this figure into perspective, this means that in 2011 there were around 746 prescriptions for antidepressants per 1,000 people in the UK, while in the United States there were around 843 prescriptions per 1,000 people. This amounts to a difference of around 100 prescriptions.142 Naturally many sociocultural factors contribute to why doctors in the United States prescribe more antidepressants, but once again we cannot dismiss the role of marketing. After all, the United States is the only country (with the exception of New Zealand) where direct-to-consumer advertising of psychiatric drugs is permitted. This means that in the United States adverts for antidepressants can be placed freely in public locations—on trains and buses, on stations and billboards, in magazines, on television, and on the Internet.
The pharmaceutical industry takes this form of advertising very seriously, spending billions of dollars on it every year.143 And it justifies this huge expenditure both in terms of its being a wise investment and in terms of its providing an important public service—one that increases public awareness of undiagnosed disorders such as depression, and one that therefore alerts people to problems that may otherwise go untreated. Countries that reject direct-to-consumer advertising often offer the counter argument that the education of patients and physicians is surely too important to be left to the pharmaceutical corporations, whose ability to produce unbiased information can’t be guaranteed. Consider, for example, the following series of US adverts all of which make scientific-sounding claims that don’t stand up to serious scientific scrutiny.
In a recent advertising campaign for a drug called Abilify, which is prescribed to people diagnosed with bipolar disorder and depression, a commercial claimed that it works in the brain “like a thermostat to restore balance.”144 Its print advertisements also claimed that “When activity of key brain chemicals is too high, Abilify lowers it. When activity of key brain chemicals is too low, Abilify raises it.”
Another example was the widely televised Zoloft commercial, which again plays on the chemical imbalance idea. It states that “Prescription Zoloft works to correct this imbalance,” even though not a single piece of research has ever confirmed what a so-called “correct” chemical balance looks like.
Then there is the advert for Paxil that reads “Just as a cake recipe requires you to use flour, sugar, and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.”
Advertisements for other big-selling antidepressants such as Prozac and Lexapro have made similar claims, again in the absence of scientific support.145 One of the first direct-to-consumer pamphlets produced by Eli Lilly for Prozac, for example, stated that: “Prozac doesn’t artificially alter your mood and it is not addictive. It can only make you feel more like yourself by treating the imbalance that causes depression.” The fact that the chemical imbalance theory has never been proven does not seem to matter to these corporations, which have made their public assertions as though they were based on scientifically established certainties.146
In these cases it is clear that pseudoscientific claims are being misused to sell the idea that our problems are largely biological in origin and so best remedied with costly bio/chemical solutions. In 2011, I encountered a particularly brazen example of how far such misinformation will go. In a video promoting antidepressants on the APA’s website, we overhear a father reflecting upon his son’s depression and how it led to a catastrophic end. The father says:
“I did not understand that depression was a disease. If he’d been a diabetic, I’d have gotten him insulin. I told him ‘get over it, you’ll feel better later.’ I used to think medication was mind control. When he stopped his therapy, he got worse. When maybe he could have been helped …”
The most chilling part comes at the end of the video when the father turns to his other son and says forlornly, “I have got some bad news about your brother …”—implying that his untreated depressive brother had finally taken his own life.147
The promotional video drives home a number of misleading messages that play on public fear and confusion around mental health issues while exploiting the viewers’ trust of medical experts. These messages imply that depression is a disease like any other physical disease (a view research doesn’t support), that medication is really the only solution (another unsupported view), and finally that not giving your child medication may lead to their death (a gross overstatement by all accounts). This video therefore taps into our anxiety that if we don’t defer to drug treatments, then we may only have ourselves to blame if tragedy ensues.
This kind of pseudoscientific scaremongering should have no place in respectable medicine and even in medical marketing, but research now indicates such tactics are used in adverts for psychiatric drugs more than in adverts for any other type of medication.148
It is not just scientific authority that has been misappropriated to sell pills. Any authority will do—including the authority of celebrity. In a popular commercial for the antidepressant Paxil, the British company GlaxoSmithKline paid the American football player Ricky Williams a huge figure to discuss his “social anxiety disorder.” Elsewhere, GlaxoSmithKline has Williams saying, “It’s amazing at how much I’ve grown and how much I’ve changed and how much I went through. And of course I owe a lot of that to Janey, my therapist, and Paxil.”149 So it seems that Paxil not only corrects your chemical imbalance but also helps you to grow into a better person. The irony is that while this advert was being disseminated, GlaxoSmithKline was busily burying data about Paxil’s ineffectiveness for certain groups.
What should concern Americans more is that all the adverts above were approved by the Food and Drug Administration (FDA). But even when the FDA has to step in to ban a particular drug advertisement (as they eventually did with the even more misleading commercials for Sarafem), those adverts will still be aired. This is because, contrary to what many people believe, the FDA does not assess pharmaceutical advertisements before they are released. Instead, it only monitors advertisements once they are disseminated, which means that fraudulent messages can still do the rounds (and so do their work) before they are axed.150
While many doctors are savvy about the cozening claims of “pharma fraudulence,” the evidence is that they still have a significant impact on doctors’ prescribing habits as well as expanding the antidepressant market.151 This is because consumers are influenced by the adverts and go to their doctors to demand the promoted pill, which doctors in turn prescribe. An innovative study published in the Journal of the American Medical Association demonstrated this by gathering together a group of pseudo-patients who were trained to behave as patients. They were sent to different primary care physicians to see what would happen if they asked for a particular drug.
The results were revealing. Out of the one hundred pseudo-patients who asked their doctors for Paxil, a full thirty-two received Paxil, while out of the ninety-nine pseudo-patients who just made a general request for any antidepressant, only six received Paxil—a result indicating that what doctors prescribe is significantly affected by what patients demand.152
While direct-to-consumer advertising is prohibited in Canada, the UK, and in the rest of the European Union,153 pharmaceutical companies still manage to get their message across to the public in these countries too, often via the more circuitous routes of media and Internet resources. For example, in the UK today there are an ever-growing number of mental health professionals who receive money from drug companies while at the same time contributing to public debates in prominent newspapers and online magazines, often presenting in these contexts positive messages about antidepressants.
The problem here is that audiences rarely know about their industry ties, because media outlets are not obliged by law to report them. To give you just one example: In 2011 I read an article published on BBC NewsOnline extolling the virtues of antidepressants.154 What concerned me was not its recommendation for wider antidepressant use, but that the citation at the foot of the article stated the author has “given lectures on behalf of a number of pharmaceutical companies.” When I further researched these company ties, I found that the citation omitted that the author had actually received consultancy fees and honoraria from many pharmaceutical companies including Janssen-Cilag, Eli Lilly, AstraZeneca, Bristol-Myers Squibb, Otsuka, and Wyeth. The thousands of people who read this article were not informed that this author was a paid pharmaceutical consultant.
After pressing the BBC, the health editor finally conceded to change the citation to reflect this potential conflict of interest (which can now be seen at the foot of the article at the time of writing). By changing the author’s citation I welcomed the editor’s implied admission that full disclosure is the proper course of action. But would this single admission stop similar mistakes being made in the future?
I therefore wrote to the BBC Trust requesting that BBC NewsOnline enshrines in its editorial policy the obligation for its editors to disclose whenever authors on mental health issues have financial industry links. I also included an online petition that I had started, which in the first few days of going live was signed by over one thousand mental health professionals (psychologists, counselors, psychiatrists, and psychotherapists). I explained to the BBC Trust why this issue was so important to us, citing further evidence where BBC NewsOnline had failed to declare its antidepressant commentator’s financial ties on many occasions. For example, in 2009 alone, I found the following cases:
In the article “Antidepressants ‘Work Instantly’” (October 2009), the same Dr. Michael Thase (who trained Carlat in New York) was quoted supporting antidepressants. We weren’t told he has acted as a consultant to AstraZeneca, Bristol-Myers Squibb, Cephalon, Cyberonics, Eli Lilly, GlaxoSmithKline, Janssen-Cilag, MedAvante, Neuronetics, Novartis, Organon, Sepracor, Shire US, Supernus, and Wyeth; is on the speakers bureaus of AstraZeneca, Bristol-Myers Squibb, Cyberonics, Eli Lilly, GlaxoSmithKline, Organon, Sanofi-Aventis, and Wyeth; and has equity in MedAvant. In the article “Antidepressants Not Overused” (September 2009), Dr. Ian C. Reid was extensively quoted, again supporting the prescribing of antidepressants. We weren’t told he’s received consultancy and speaker fees from Sanofi-Aventis, Wyeth UK, Eli Lilly, and AstraZeneca. In the article “Drugs can Help Mild Depression” (May 2009), Tony Kendrick was also extensively quoted supporting antidepressant use. Again we weren’t told he receives fees and funding from Eli Lilly, Lundbeck, Servier, and Wyeth pharmaceuticals.
Upon discovering these and other undeclared interests, I argued that the BBC was in effect giving the green light to the pharmaceutical industry (albeit unknowingly) to promote and/or advertise antidepressants, via paid consultants on its website, by not informing readers as to their paid status. I requested that the BBC Trust take editorial action to ensure the public will be better protected in the future from such editorial mistakes occurring again.
It took ten months for the Trust to respond. I finally received a response on November 19, 2012, from Francesca O’Brien, head of editorial standards at the BBC Trust. Here is what it said:
Dear Dr. Davies,
Thank you for raising your concerns as to how the BBC signals that contributors have competing personal, professional, or financial interests when they appear in BBC content …
The Trustees found the issues you raised following your complaint in January 2012 thought-provoking and helpful.
The Committee considered your concerns in the light of your complaint about the transparency and accuracy of science coverage. The Committee appreciated that you wanted the Trust to consider the general question of whether the Editorial Guidelines should be revised.
The Committee agreed that there was nothing in principle to prevent the Guidelines being amended prior to their scheduled revision. However, the Committee was satisfied that the issues raised were covered by the current Editorial Guidelines in their totality. The Committee felt that if the Guidelines needed to be more explicit, then that was something to consider at the time of the next revision. I will ensure that this is an issue that is included upon the agenda at the next revision.
In the meantime, however, the Committee agreed that there would be a benefit to the Executive reminding BBC News of its obligations to make careful editorial judgments about signposting any potential conflicts of interest among its contributors.
The Committee therefore agreed to ask the BBC’s Director of Editorial Policy & Standards, David Jordan, to remind BBC News of these obligations.
Yours sincerely,
Francesca O’Brien
Head of Editorial Standards, BBC Trust
The result could have been better (i.e., there is no admission that the current editorial guidelines fail to oblige editors to cite financial conflicts of interest). But on the other hand, it could also have been worse (there is at least an expressed commitment to tighten editorial judgments in the future). So all that remains is to continue to monitor closely BBC News articles to ensure these obligations are kept, as well as to continue lobbying for a change of guidelines at the next review.
As for the countless other news outlets regularly reporting on antidepressants, things look far less sanguine. Short of a national media commitment to making these ties entirely transparent, we must continue to be wary of what we read in the news.
5
When we pull together the facts of all the preceding chapters, an underside of psychiatry begins to emerge with which most people are unfamiliar. The underside is that whenever someone ostensibly benefits from a psychiatric prescription, the pharmaceutical industry and many within psychiatry benefit too. The question must be, therefore, who benefits more?
Once again, where you sit will determine your answer. After all, those who enjoy industry ties usually defend their importance robustly, stating they inform research and facilitate the creation of better drugs, which in turn can only better serve struggling patients. But that is not the story here. Our story reports a different version of events, one that gets far less publicity and one that you must decide for yourself how far you are willing to subscribe. That alternative vision in its most unvarnished form goes like this:
The categories of mental disorder (rather than painful experiences themselves) are psychiatric constructions and not scientifically discovered biological entities. As these categories have greatly proliferated in number in the DSM and ICD, psychiatry has reclassified more and more of our natural human behaviors and feelings as psychiatric disorders requiring treatment. By doing so, psychiatry has not only expanded its jurisdiction over more of us (one in four of us apparently now suffers from a mental disorder) but has also, by inflating the number of mental disorders, created a huge market for psychiatric treatments.
The preferred treatments are pharmaceutical treatments such as antidepressants and antipsychotics. But the emerging reality is that these treatments don’t actually work in the way most people believe. In the case of antidepressants, mostly they have placebo effects, negative effects, and sometimes mind-numbing effects. But never can we assume they have curing effects, largely because for the vast majority of disorders listed in the DSM there is no discernable “disease” that these pills target and treat. So while suffering is a reality, and people deserve help, that is worlds away from justifying the assumption that most or all emotional suffering is caused by disease, brain disorder, or chemical imbalance.
These inconvenient facts are not generally known, partly because pharmaceutical corporations have promoted misinformation through concealing negative data, through powerful marketing campaigns costing billions of dollars a year, and through conducting research that regularly chops the figures in ways advantageous to company interests. One reason why psychiatry has tolerated this more than it should is because too many doctors, research centers and researchers, and too many DSM committee members—that is, too many leaders within the psychiatric profession—have had their objectivity compromised by the pharmaceutical funds upon which they have come to depend.
I offer the above as a hypothesis that I believe the facts presented in the preceding chapters oblige us to take very seriously. But whatever the extent to which you subscribe to this hypothesis, there is one proposition that most of us, wherever we stand, would find very hard to discount: that “biological” or “pharmaceutically sponsored” psychiatry has slowly, imperceptibly, but most assuredly begun to alter the way in which many of us now manage, respond to, and experience our emotional discontent.
Precisely what form this alteration has taken and what its implications may be is a matter that I will now pursue in the next chapter.