August 2008

Elizabeth Bachner

features

Reading About Prozac

Listening to Prozac: The Landmark Book About Antidepressants and the Remaking of the Self, Talking Back To Prozac: What Doctors Aren't Telling You About Today's Most Controversial Drug, Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives, America Fooled: The Truth About Antidepressants, Antipsychotics And How We've Been Deceived, Potatoes Not Prozac: Solutions for Sugar Sensitivity, Natural Prozac: Learning to Release Your Body's Own Anti-Depressants, The Antidepressant Survival Guide: The Clinically Proven Program to Enhance the Benefits and Beat the Side Effects of Your Medication, Puppy Chow Is Better Than Prozac: The True Story of a Man and the Dog Who Saved His Life, Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression, Is It Me or My Meds?: Living with Antidepressants, Pregnant on Prozac: The Essential Guide to Making the Best Decision for You and Your Baby. A Child Called Prozac. Eat, Pray, Prozac. I’m only making some of these up.

Welcome to depression. In 2002 alone, 11 million antidepressant prescriptions were written for the under-eighteen set, 2.7 million of those for kids under twelve. The prescription of antidepressants to children and teens tripled between 1994 and 2002, to the point that they were more-prescribed than acne medication. Between 1998 and 2002, underage prescriptions for the SSRI (Selective Serotonin Reuptake Inhibitor) Paxil doubled, even though there was no evidence that the drug performed any better than sugar-pill placebos in treating pediatric and adolescent depression. According to a Miami Herald article, 45% to 46% of foster children, some as young as five, were on psychotropic drugs. Adults were (and still are) popping these pills like crazy, too, for everything from faint shyness to losing a loved one to feeling sad.

When antidepressants became a staple of everyday American life, a new genre of literature also exploded into the mainstream: Prozac Lit. The genre has couple of subsets -- potboiler memoirs (Marya Hornbacher’s Madness: A Bipolar Life, Elizabeth Wurtzel’s Prozac Nation), which can be kind of fun, and books that tell The Truth About Antidepressants. This latter breed of sensational Prozac Lit sometimes plants itself squarely in one camp or the other -- celebrating or reviling SSRIs (Selective Seratonin Reuptake Inhibitors) like Prozac, Paxil and Zoloft -- but many are smugly centrist. Reading these books is, well, depressing. The pro- and anti-pill screeds are innocuous. It’s the earnest, aw-shucks accounts of how “antidepressants are sometimes misused, but they’ve also have helped millions of people” that cloy. In a lot of Prozac Lit favorites, the systems that govern how drugs are created, how they’re tested and how they reach the public go unexamined.

Some ramp up their readability with case studies. In Prozac Backlash, Joseph Glenmullen’s patient, “Sharon,” the thirty-something mother and freelance journalist, tells him:

 “I feel like an adolescent boy with a perpetual hard-on who can’t get any action… The worst part is that my appetite for sex isn’t dampened, just my ability to really enjoy it. Help!" She grinned ruefully.

"It might be the Prozac, you know." I responded.

"I figured," said Sharon glumly. "It’s awful.”

He asks if Sharon is sure she wants to stay on the drug. Yes, she says, “I’ve still got four major articles due in the next six months. I can’t afford to get depressed again.” He decides to take Sharon off Prozac, wait for the sexual dysfunction to clear, and then start her on Zoloft.

Sharon’s ability to orgasm returned within two weeks after stopping the Prozac. "There’s no question the drug was the culprit," Said Sharon… Unfortunately, at the same time Sharon could feel the depression returning. "In the morning, I can’t get out of bed to face the day… After I drop Jenny and Clara off at school. Back home I can’t face a page. I can’t lift a pen to write."

I’m kind of like Tom Cruise. Well, other than his being a rabid, movie-star Scientologist with a tall, clunky wife from Toledo who hangs rapturously on his every word, and his weird mania, and Top Gun and Cocktail. So, I’m unlike Tom Cruise except that, like him, like “Scientologists and other anti-drug wackadoos” (to quote Joel Tannenbaum at Philadelphia City Paper), I fall squarely into the anti-antidepressant camp, at least for people like “Sharon.” First of all, the fact that placebos are so effective in clinical trials is telling. For people who are not suffering from physiological symptoms of severe neural and hormonal disorder, but are “nervous in social settings,” “feeling sad” or “having trouble getting up in the morning and facing the day,” an artfully labeled sugar pill often does the trick. So, doesn’t it make sense to try side effect-free treatments -- which do not interfere with one’s ability to have orgasms, make artwork or experience emotions vividly -- first? Second, the drugs have super-horrific side effects. One old ad for taking Paxil for Social Anxiety Disorder made me wonder how the side-effects described (nausea, depression, increased sweating, tremors, anxiety, out-of-control urinary and bowel movements, “sexual side effects” and possibly wanting to die) would be an improvement on feeling anxious in social situations, and also, if the Paxil did make you feel bold, relaxed and friendly, but you got shaky and diarrheaic anyway, well, what was the point?

Third, production, testing and marketing of the drugs is ethically suspect. There was a product-placement subplot on Everwood, a show designed by the Family Friendly Programming Forum, a coalition of advertisers including three of the top teen-psychiatric drug manufacturers, GlaxoSmithKlein (Paxil), Novartis (Ritalin) and Pfizer (Zoloft). Amy, an Everwood teen, was suffering from depression because her sweetheart Colin (long in a coma) dropped dead. Amy needed Paxil or Zoloft, whichever was right for her -- never mind that at the time, the FDA had not approved prescription of these drugs to minors, since studies were turning up some unsettling evidence that SSRIs made some teenagers who had always been ordinary, or a bit depressed and anxious, want to hang themselves and slit their wrists. Once you learn about the FFPF, it gets easier to identify the child-targeted advertising folded semi-seamlessly into popular TV shows. Because competing products get spots in the same sequence (Coke and Pepsi, Paxil and Zoloft), and some of the portrayals of products are negative or mixed, many viewers can’t tell that they’re watching an ad. And building brand loyalty before kids are old enough to drive has proven much more effective than trying to sell things, transparently rather than stealthily, to adults.

As for “Sharon” and her husband “Matt,” has she ever considered that maybe she’s just plain miserable, plodding through everyday life, with too many deadlines and “Matt” not helping out with the kids enough and, orgasms or not, a lack of daily pleasure, decadence, and rest? Has she ever considered that it’s not an issue of “brain chemistry,” but that her life sucks? According to an essay in his book Monkeyluv, neurobiologist Robert M. Sapolsky suggests that even our genes change based on our daily lives. Nature and nurture are so interconnected that it’s a false dichotomy. “Hardwiring” is a chicken-and-egg issue -- drugs can change your brain chemistry, but so can running, holding a puppy, meditating and happiness.

As a relatively privileged person like “Sharon” -- a person who is not struggling to find a safe place to sleep outside in a dirty city every night, or to pay off a debt to a scary, violent pimp while protecting my eight-month-old -- I would rather try depression treatments like vinyasa yoga six days a week, gelato, jogging, Swedish massage and a long vacation than something that might cause renal impairment, panic attacks, weight gain, a loss of orgasm, suicidal thoughts or, worse, a bland placidity where my personality used to be. No matter what arguments I hear that depression has to do with “hardwiring” or “chemical imbalances” and medicating it is “like taking Aspirin for a headache,” I can’t shake the idea that feeling really bad is a message from our unconscious, evidence of our sentience, telling us that we are suffering from grief or trauma or crippling boredom, that our jobs were not chosen out of passion, that our relationships are making us insecure -- urging us to hop out of the boiling water of our lives. It’s like physical pain. If we break an ankle, it hurts to try to walk on it, because to heal, we’ve got to lay off the ankle.
Some of my meds-loving friends get furious with me for this attitude. “You don’t understand what it really means to suffer from clinical depression,” they tell me. It’s true. If clinical depression is something that’s truly unaltered by anything in the outside world -- getting into peak physical shape (starting with baby steps, like walking to the corner, if you’re too sad to move), traveling the world, quitting a lousy job -- then I’ve never suffered from it, except when I tried birth control pills, and then I could tell that it wasn’t “me” feeling depressed, the way you can kind of tell when someone pops a roofie into your 7-Up. I understand the need to develop safe, effective treatments for people with postpartum depression, severe trauma and other highly dangerous mental health issues, although it doesn’t seem that Big Pharma is too interested in exploring the widest variety of possible treatments. But someone like “Sharon,” or most of the case study subjects in Prozac Lit? Her brain isn’t going haywire, causing her to hear voices that tell her to murder her children or to feel limbs on her body that aren’t there. She just doesn’t like her life.

Prozac Lit is largely geared toward people like me -- people who are not psychiatrists or other mental health professionals. People who will, hopefully, be swayed and lulled by pop-science factoids -- on the Tom Cruise side or the Big Pharma side -- into overlooking the deeper issues that are causing us, as a society, to drug a whole generation of children. I don’t have a leg to stand on in my Tom Cruise rants, but it’s clear that something’s very wrong -- something so pervasive, so systematic, and so taken-for-granted that even with all the evidence right out there in the open, somehow no one can see it.

In 2002, we drugged 11 million under-18-year olds. At that time, before all the facts came to light about how big pharmaceutical companies like GlaxoSmithKlein had concealed evidence that their SSRIs gave a goodly number of previously non-suicidal teens the urge to hurt themselves badly enough to die (see below), we already knew about the lesser side effects of these drugs.

Actually, I feel more like J.M. Coetzee’s Elizabeth Costello than Tom Cruise. Elizabeth, a writer, sees people eating meat around her, and can’t help but feel that she’s witnessing sickness, cruelty and murder. She tells her son:

“I seem to move around perfectly easily among people, to have perfectly normal relations with them. Is it possible, I ask myself, that all of them are participants in a crime of stupefying proportions? Am I fantasizing it all? I must be mad! Yet every day I see the evidence. The very people I suspect produce the evidence, exhibit it, offer it to me. Corpses. Fragments of corpses that they have bought for money. It's as if I were to visit friends, and to make some polite remark about the lamp in their living room, and they were to say ‘Yes it's nice isn't it? Human skin it's made of, we find that's best, the skins of young virgins.’ And then I go to the bathroom and the soap wrapper says ‘100% human stearate.’ Am I dreaming, I say to myself. What kind of house is this? Yet I'm not dreaming. I look into your eyes, into your wife's, into the children's, and I see only kindness, human kindness. Calm down, I tell myself, you are making a mountain out of a molehill. This is life. Everyone else comes to terms with it, why can't you? Why can't you?'”

Thankfully, along comes Side Effects: A Prosecutor, a Whistleblower, and A Bestselling Antidepressant on Trial, by journalist Alison Bass. It’s not a profound work of ethical philosophy or a deep social critique. It’s written in a style that’s a bit dumbed-down, and there’s a weirdly 1970s atmosphere to the scenes and character descriptions -- it often reads more like a ghostwritten celebrity biography than like Truman Capote or Christopher Hitchens. But it’s an important, hope-raising breath of fresh air -- a simple, old-fashioned work of muckraking that documents the human skin all over the lamps at Pfizer, Eli Lilly and GlaxoSmithKlein, and discusses how it got there in a way that the average thoughtless, earnest, credulous, pitiful reader of Prozac Lit can understand. Muckraking has never been for the lily-livered, and Bass lays out her case step by step: Big Pharma has defrauded the public about the safety and effectiveness of SSRIs. The U.S. Food and Drug Administration (FDA), the government body responsible for protecting pharmaceutical consumers, is owned by, and subservient to, Big Pharma.

The facts, stacked up neatly in the center of the room, sing: In 1992, Congress passed the Prescription Drug User Fee Act (PDUFA), which offset scientific research costs by getting the drug companies to pay for clinical trials. In 1993, $8.9 million for drug testing came from Big Pharma -- 7% of the FDA’s total drug review budget. By 2004, $232 million, or 53%, of the FDA’s drug review budget came from big Pharma. As Bass puts it, “Many public health advocates believe that the PDUFA ultimately ended up making the nation’s preeminent health agency beholden to the very industry it was supposed to regulate.” Throughout Side Effects, Bass shows how, at every level, people taking handouts from pharmaceutical companies pony up the research results the funding source wants.

The prosecutor in Bass’s title is Rose Firestein, a deceptively tiny, nearly blind powerhouse working with then-New York Attorney General Elliot Spitzer. She’s the one who figured out that the Attorney General’s office wouldn’t need to put the efficacy of Paxil on trial -- they could just show how GlaxoSmithKlein, Paxil’s manufacturer, was guilty of “repeated and persistent fraud,” and had routinely and intentionally deceived physicians and consumers about the drug’s safety and effectiveness.

The whistleblower is Donna Howard, an employee at Brown University whose boss, Martin Keller, was running trials of Paxil, funded by GlaxoSmithKlein, on teens. Howard, herself the mother of a foster child who had been diagnosed with multiple mental health disorders, noticed that Keller “was playing fast and loose with the protocols for the Paxil study” when she noticed that two teens who had tried to commit suicide while on the drug had been yanked from the study for “noncompliance.” (According to FDA research guidelines, each “serious side effect” -- suicidal thoughts, hostile behaviors, dizziness, nausea, headaches, chest pain -- must be meticulously recorded and coded.) She also uncovered inconsistencies in other Keller-headed studies -- a different number of teens was reported in a Lithium trial grant proposal than were actually in the study, and Keller was collecting money from the Massachusetts Department of Mental Health for a schizophrenia study that appeared not to exist. She risked her career to go public with what she found.

Other players are Martin Teicher, a psychiatrist who went public with his observation that SSRIs were making some of his patients suicidal, and Tonya Brooks, a girl who asked her doctor for Paxil when she was sixteen, because she was shy around other kids. She saw an ad for the drug featuring a happily medicated teen boy. After going on the Paxil, her behavior became furious and dangerous -- she screamed at her parents, gauged herself with her dad’s X-acto knife and tried to kill herself. Brooks, along with dozens of other kids who had become suicidal on Paxil and their parents, sued GlaxoSmithKlein. Bass herself, whose coverage of pharmaceutical industry corruption in the Boston Globe helped prompt public attention and investigation, doesn’t toot her own horn too much in her book, but she’s also a heroine of the story.

Firestein’s suit prompted the FDA, in October 2004, to order black box warnings on all thirty-two antidepressants currently on the market. In March 2006, prompted by an FDA-mandated review of SSRI data, researchers at GlaxoSmithKlein re-examined five studies of Paxil and uncovered ten previously unreported cases of suicidal behaviors and thoughts among the children and teens on the drug, four of them in Martin Keller’s study. They concluded that “suicide-related events” occurred almost four times more often in kids taking Paxil than taking a sugar-pill -- an almost 50% greater risk than the rate of suicidal behaviors found in the FDA’s first reanalysis two years before. In 1999, Brown University agreed to return $300,170 of taxpayer money to the state of Massachusetts for the schizophrenia research that Martin Keller their psychiatry department never performed, yet at press time for Side Effects, Brown was still supporting Keller. His department receives $50 million in research from external sources, including Big Pharma and the taxpayer-funded National Institute of Mental Health. He refused an interview with Bass, but a Brown spokesperson told her, “Brown takers seriously the integrity of its scientific research. Dr. Keller’s research regarding Paxil complied with Brown’s research standards.” On July 14, 2008 Bass reported on her blog that Iowa Senator Charles Grassley is now leading an investigation of Martin Keller. Will this force Brown to change its position? It’s clear from Side Effects that Keller brings in so many bazillions of dollars precisely because his research (when it exists) is made-to-order.

It’s not yet 2540 AD (or, the Year of Our Ford 632, when Aldous Huxley’s Brave New World begins), and we don’t have a peaceful society. Like the people of Huxley’s dystopian World-State-dominated London, though, we are drugged to the gills, and we even drug kids to keep them from acting up. (One twelve-year-old foster boy mentioned in Side Effects is given Haldol -- a fierce antipsychotic with alarming side effects, intended only for adults having severe psychotic episodes -- because his father has just died.) In Huxley’s New World, independent thoughts are discouraged, constant consumption is paramount, and reading is considered a great waste of time. Books like Brave New World (and pretty much every good novel) are banned and censored in every era, precisely because they encourage complex and heterodox thinking, because they make us take a fresh look at what we take for granted in our society and culture. Then again, books are powerful as propaganda, too. Either way, they are powerfully persuasive. What happens, though, when books cease to be innovative or propagandistic, and instead turn bland, their tenets so taken-for-granted and their tone so dumbed-down that their ideological bent is hidden in plain sight?

That’s why Prozac Lit is such an insidious genre. It’s too easy to come down on one side or the other about Big Pharma -- Big Pharma is evil and corrupt, or Big Pharma is good because drug companies have developed indispensable tools for saving human lives -- without really seeing the minute latticework of this crime of stupefying proportions. What is so stupefying, to Elizabeth Costello, isn’t that a great, evil social order has come from above to commit mass murder. It’s that everyday, pleasant people are contributing to a sick order, and it doesn’t seem to occur to them than anything is wrong.

Whistleblowers are needed, and muckrakers, and champions of justice. “In the three years since the New York State AG’s office shone a spotlight into the black hole of drug research, there has been a growing outcry about the enormous influence the pharmaceutical industry wields over the practice of medicine,” writes Bass. It falls to writers and journalists to frame the issues, to show up the crimes in plain sight that everyone is overlooking. Books like Side Effects build momentum. But even then, if everyday people can look on and see nothing wrong -- if Brown University sees nothing wrong with Martin Keller’s ethical practices, if government officials see nothing wrong with using potentially dangerous drugs as a “chemical babysitter” for foster children, if TV viewers are happy to see integrated product placements for SSRIs woven into youth-targeted programming -- well, we’re stuck, like Elizabeth, washing our hands with soap made from people.