In the past twenty years, the number of prescriptions for anti-depressants has sky rocketed across the globe. The anti-depressant market has grown into a multibillion dollar industry with the confidence of the general public and most of the medical profession. SALIENT Editor James Robinson asks: in the race to medicate our unhappiness, what are the side effects?
On the 24th June, 2005 The New York Daily News reported that Tom Cruise had attacked Brooke Shield’s use of antidepressants. Cruise was widely heralded as a lunatic for making such claims, making sure the opponents of the drug were seen on a level of craziness currently reserved for Scientology in society. The newspaper writes (in what can only be described as a truly, truly objective fashion) “the actor arrogantly told the newsman”, and refers to Cruise as “proselytizing”. But Cruise was not trawling for new Scientology recruits. His views on antidepressants are representative of a credible sector of the Science community. However last week his contract at Paramount was not renewed, with his views on anti-depressants widely seen as a reason for the severance of this relationship. The outcry against Cruise is indicative of the irrefutable status in people’s minds of the healing power of anti-depressants. To oppose it is lunacy on the level of Scientology.
And why not? The use of anti-depressants grows each year at an increasing and ever-astounding rate. In the United States, the anti-depressant ‘industry’ is worth 14 billion dollars in sales a year, with 11 million prescriptions being written out to kids between the ages of 0-17 alone with the fastest growing segment of that bracket disturbingly being children 5 years old and younger. In New Zealand there were roughly 944,000 prescriptions written in the year ending June 2005, making for over 2 million dispensings. It fluctuates, but each year the number of people on anti-depressants grows by around 10 percent. In 2005 through PHARMAC – the government organisation in charge of drug subsidies – anti-depressants were subsidised to the tune of 27.3 million dollars, making them the sixth most subsidised drug in this country. In this country depending on the level of subsidy that you qualify for, they will cost you between zero and fifteen dollars, a small price for piece of mind.
There is no doubt that the push in this country to remove stigmas around mental illness is a valuable and important movement. But is the offshoot of this a rush to medicate our own personal sanity? Troublingly also, behind the upwards trends and government subsidies, lie tragedies as well as success stories. Everyone seemed to have a story to offer this article, from the thankful people who saw a loved one pulled out of a rough patch, to the angry people who saw a cherished friend transformed into someone they did not recognise. Whether a user or not, today, everyone is affected by the drugs. It just doesn’t seem that we’re okay talking about them.
In New Zealand, statistics from the New Zealand Mental Health Organisation show that one in every five women, and one in every ten men are liable to have a major depressive episode in their lifetime. One in every five people presenting to a GP have suffered a depressive episode in the last 12 months. Statistics also show that the rates of depression are ever increasing. New Zealand youth are reporting increasingly high levels of depression and this is transferring over into adulthood. Women are hit harder than men, 18 % of all secondary school level girls are estimated to be in need of medical help for depression. The World Health Organisation estimates that by 2020 the second highest cause of death and disability in the world will be, you guessed it, depression.
Judi Clements is the Chief Executive of the New Zealand Mental Health Organisation, an organisation that works towards making mental-health “everyone’s business.” Twenty-seven years young, the organisation works to increase mental health and wellbeing, through increasing consideration of mental health needs across the board in society. Clements says attitudes towards mental health have changed considerably. “In the last 15 years or so there has been a substantial move away from putting people out of sight, and a lot more emphasis on community support.” Clements points at recent Ministry of Health surveys that show very positive trends in terms of general awareness and tolerance.
“In trying to destigmatise mental illness, people are less hesitant in seeking help.”
Has this opened up the floodgates? The stigma has disappeared slightly from mental illness, and rightfully so. But when the numbers are considered, the Mental Health organisation, and their subsidiary organization ‘Out of the Blue’ seem a little late with their ‘you are not alone’ message. Clements says that: “in trying to destigmatise mental illness, people are less hesitant in seeking help.” People are recognising the effect that mental health issues do have an effect on their life. And a significant amount of people have come forward.
An increase in anti-depressant use has gone hand in hand with the surge in classified cases of depression. And as the two figures go up at similar rates, it is evident that medication is very much relied on as a treatment for depression. Fluoxetine was created by the US drug company Eli Lilly in the early 1980s, and approved for distribution in 1988, soon going by its more common name Prozac. It took off quickly. The initial marketing of Prozac is seen as a revelation, and the most successful pharmaceutical marketing campaign ever. Eli Lilly lost the patent for Prozac in 2001, but by then it was already a many billion-dollar industry. As numbers sky-rocket, price heads in the other direction. A report to the incoming Minister of Health in 2005 shows that in 2005 340,000 more prescriptions were handed out for anti-depressants than in 1997, but spending on the drugs decreased by $1.5 million.
For Clements though, anti-depressants fit in as an option for health practitioners, and are part of a wider spectrum of treatment and rehabilitation. “They can be useful, but they should not be considered the first port of call.” Clements points at other possible methods of relieving symptoms of depression, like exercise, and says that in her view anti-depressants work best when combined with counseling. You have a rush of people feeling confident in talking about unhappiness and depression and a wonder drug that can supposedly end unhappiness. Are the two linked? Are too many people on anti-depressants? Clements says that, “it is impossible to say whether too many people are on them.”
“There is a consistent body of research that for clinically depressed people the best outcomes, both in terms of recovery and the maintenance of that recovery, is provided by a combination of anti-depressant medication and cognitive behaviour therapy.” John McDowall
Dr. John McDowall, a psychology lecturer at Victoria University tells me: “depression can be a severely debilitating illness, causing major disability to those affected. Antidepressant medication has a major role to play in lifting mood and overcoming some of the other symptoms of depressions.” It is important however, and a far more reliable way to prevent a relapse, for the medication to be used in combination with cognitive behavioural therapy. “There is a consistent body of research that for clinically depressed people the best outcomes, both in terms of recovery and the maintenance of that recovery, is provided by a combination of anti-depressant medication and cognitive behaviour therapy. For less severe depression, cognitive behavioural therapy alone has proved to be effective.”
The drugs do work for some. One user of anti-depressants talks of going on the drugs because he “wanted to kill himself.” Now fast-forwarded down the track, he is not using them. “Mr. X” says that he did suffer some negative consequences from being on the drug, “my mother found out about the drug and panicked, giving me this big old Catholic guilt-trip. I was too depressed to actually remember to take it most of the time. Physically, I gained weight and had mild feelings of euphoria. I also found it hard to answer questions.” X went through 18 hours of evaluation before being placed on anti-depressants, and talks of the importance of combining anti-depressant use with counseling – “the drugs got me to sleep, but the psychiatric counseling works wonders.”
He describes it as the best thing ever happened to him. At Victoria he is among many who seek help for depression at Student Health. The medical director at student health at Victoria, Dr. Thaw Naing, tells me that depression is one of the most regular complaints they get. “Generally speaking you could say that it is a common presenting symptom. When we hire a new GP we ask them if they have had any prior experience with mental health, because it is such a very common concern.”
Naing says that once a patient has come in their next consideration is what sort of depression they are suffering from, what category and subtype it might fall into. Unsurprising, stress is a huge factor at a university medical centre, and in today’s climate where students have to earn and study at the same time, you can almost understand the demand. “The majority of the cases are stress related,” Naing tells me, “but more of the cases fall into the mild to moderate category, than the moderate to severe.”
Naing’s take on why the numbers of people presenting with depression are increasing dramatically is similar to Clements, but it is three-fold. Naing believes that stigmas around mental health have declined, though he does admit that doctors often have to overcome a stigma of patients “not wanting to be dependent on anti-depressants to be normal. It’s a barrier we have to get across before we can even get the patients to take anti-depressants.”
“We try to explain that depression can affect anyone, it’s like any other medical condition, it’s nothing to do with your weakness or your strength.” Dr. Thaw Naing
Naing says that doctors are also probably diagnosing a lot more, but also that general awareness is on the up. More and more people are recognising the symptoms in themselves and coming forward for medical help. He points to more people coming in off the street who have consulted resources on depression themselves before coming in, which he feels is commendable. “We try to explain that depression can affect anyone, it’s like any other medical condition, it’s nothing to do with your weakness or your strength.”
Anti-depressants have improved in the last 20 years Naing says, and that is why more people find it acceptable to go on them. They are more specifically targeted to areas of the body, they are non-drowsy and Naing comments at one point that they can be seen like an antibiotic for the mind. “Depression is treatable, and these drugs do work. I’ve had a number of students coming back in and saying ‘I don’t really remember what I was like, because now I am so OK.’ Before, antidepressants were like shooting a shotgun, you fire off all these pellets and eventually you’ll hit something. There were terrible side effects and people were put off.”
Naing tells me though that not every patient that who is depressed is suited to anti-depressants. Student Health work closely with the counseling service and consider biological, social, and psychological issues for a patient before prescribing. “A patient will not be prescribed first time,” Naing adds.
Beneath all the medical affirmations and sky rocketing patient numbers, however there is a growing discontent with these newer, better, and more popular anti-depressants. There seems to be an alternative history to anti-depressants that is not so apparent. Even Mr. X, for all his praise of the drugs, admitted to not knowing anything about any possible side effects. One former Prozac patient told me of being prescribed anti-depressants after one visit to the GP, and noted that she felt there was “a large gap between what the doctors tell you and what you actually hear from patients that are on the drugs.” That same patient talked of a series of vivid nightmares she had after going on the drugs. Prozac, and similar drugs such as Paxil, and Aropax that fit into the Selected Serotonin Reuptake Inhibitors ( S.S.R.I.) family, do have severe side effects that manifest in varying persistency – depending on the patient. The side effects are listed as drowsiness, dry mouth, nervousness, anxiety, insomnia, decreased appetite and decreased sexual function. And that is the ‘improved’ list of side-effects. Since the early 1990s, Prozac has been irked with outside ‘conspiracies’ that the drug in some cases increases depressive and suicidal behaviour. In the drug’s twenty-year history the company has settled over 30 lawsuits, paying out over 50 million US dollars.
A 2002 MedSafe report looks at the link between suicidal behaviour and the use of SSRIs. The report is skeptical in its tone but does not deny the link. Akathisia is described as involuntary severe motor restlessness” and is a potential side effect of anti-depressant use that in itself has been linked with suicidal behaviour, although this link that is debated – it is not dismissed.
On the home front, in the 2005 PHARMAC annual report they noted that SSRIs had “continued to come under scrutiny” for their link with suicidal behaviour. They listed it as one of the key issues they had faced for the year and recommended strongly against the prescription of anti-depressants for children and adolescents. Problematic when there was a four percent increase in prescriptions for the under 18 bracket in New Zealand in the corresponding year and even more staggering for somewhere like the US where 11 million youths are on anti-depressants. Factor into this that no one really knows when adolescence ends. Some say 17, while in the States the end of adolescence isconsidered to be your mid-twenties. It’s confusing.
This was the information immediately on offer from a routine search on the drugs. Searching a little harder, following up some footnotes on anti-depressants, I turned up another murky level of statistics.
For a start, there are a number of medical professionals who believe that anti-depressants breed dependency, physical or psychological, and that patients are being drawn into a cycle of use through withdrawal symptoms being mislabeled as a recurring bout of depression. The World Health Organisation, published a list at the turn of the millenium of drugs that are most problematic to quit. Aropax came in at number one (Aropax is the most commonly consumed anti-depressant in New Zealand) and Prozac at number seven. Valium, long joked about as the recreational drug of choice for bored housewives in the 1950s, came in down the list at thirteenth.
The company was ordered to pay out $6.4 million to the family of Donald Schell, a 60 year old man who killed his wife, daughter, and granddaughter two days after going on the drug. This came months after an Australian judge ruled anti-depressants liable for an Australian man killing his wife and attempting suicide.
A Guardian article from June 2001 looks at the case against Aropax in the US (where it is known as Seroxat) and its developers GlaxoSmithKline. The company was ordered to pay out $6.4 million to the family of Donald Schell, a 60 year old man who killed his wife, daughter, and granddaughter two days after going on the drug. This came months after an Australian judge ruled anti-depressants liable for an Australian man killing his wife and attempting suicide.
During the case against GlaxoSmithKline Dr. David Healy, the UK’s most regarded expert against anti-depressants (he has testified in court in many successful lawsuits against the drugs), was allowed access to the archives of raw data from the clinical trials from when the drug was in development. Raw data is notoriously hard to access, even for governments, and Healy being allowed to see these was a major development. What he found is damaging against the company. From an initial test pool of previously healthy subjects, 85 percent of them showed withdrawal symptoms and suffered from insomnia and nightmares after finishing the trials.
German regulators in 1984 commented on the first application to distribute Prozac that: “Considering the benefit,and the risk, we think this preparation totally unsuitable for the treatment of depression.” It’s hard to know whether they were right in concluding this, but they were right in commenting on the risks. These anti-depressants have risks. Small risks of very negative side effects are amplified by the sheer amount of people taking the drugs. In America the widely distributed Physicians Desk Reference shows that the anti-depressant Luvox reported manic reactions in clinical trials in 4 percent of children. But when you take into account the fact that 2 million kids across America take Luvox, it’s a somewhat different issue. That’s about 80,000 manic reactions.
And that’s where the debate gets tricky. It’s agreed that the drugs can be bad for you but what is not known is how bad. Naing says that: “every drug has side effects, even Panadol, it’s a fact of life that we can’t run away from.” McDowall says that weight gain and sexual dysfunction have been reported to be longer lasting side effects of the drugs. In terms of the risk to children and adolescents, McDowall says that the “exact extent of the problem is yet to be clarified” and that the “benefits still outweigh the risks.” Naing tells me that they are cautious, especially dealing with a newly adult or still adolescent age group. Addiction is something that is “generally agreed” is not an option. But aside from that I got a resounding ring of “perhaps”, “maybe” and “I don’t know” when I ran criticisms of anti-depressants past various health professionals.
But it is clear that in many circles the tide has turned slightly against anti-depressants, and the Prozac honeymoon may one day wear off very quickly when a generation of kids reared on pills grow up. There is none more a telling sign than this than the relative fall from the public grace of the drug company Eli Lilly. The company has had a near untarnished run since 1982, when it’s anti-inflammatory drug Oraflex was removed from the market after three months. Opponents take glee in pointing out that both George Bush Snr. and Ken Lay have been members of the Eli Lilly board at various points. Eli Lilly’s latest drug discovery Zyprexa was soon linked with increased risks of diabetes, and costs approximately twice what identicaltreatments cost. But when Kentucky Medicaid chose to exclude the drug due to risk and cost, the National Alliance of the Mentally Ill (NAMI) went into over drive. The supposedly neutral agency bussed in protestors and paid for full-page ads in local newspapers. A New York Times journalist soon discovered the NAMI was propped up by $36 million a year in funding from Eli Lilly, and there was a Lilly executive on permanent loan to the organisation.
Eli Lilly’s CEO Sidney Tauper made it onto the Homeland Security Advisory Council in June of 2002. It is seemingly ludicrous but bizarrely tangible that Eli Lilly’s grasp of influence includes none other than the 2002 Patriot Act. In the deepest reaches of the act, lies an irrelevant and unpublicised subsection protecting large pharmaceutical companies from lawsuits by parents whose children who were harmed by Thimerosal, a mercury based additive used in vaccines made by Eli Lilly. There was even a one off reading of a small amount of Fluoxetine in the water in Florida and a controversy when privacy was breached to send out promotional materials for Prozac. But undoubtedly the feather in the cap of the darkhorse that is Eli Lilly would be the fact that Eli Lilly himself, the man who put his name to the company worked with the United States army in 1953 in developing LSD.
It’s phenomenally tricky to reconcile the two sides. And the only way to get consensus is to agree that yes, there are benefits. But there are also severe risks. Small side effects should not, and soon probably can’t continue to be ignored, when the quantity of people on the drugs is taken into consideration. As Naing told me, “there are no hard and fast rules” with the drugs. But these rules should be developed. It is accepted that the drugs are not for everyone, yet the increase in patients on anti-depressants has increased at such a rate that it is hard not to come to the conclusion that suitability for the drugs is not something that much thought is going into. There has been a very positive movement to remove stigmas from mental health, people have the confidence to go to the doctor and seek help when they are unhappy. It would be a shame if all this good work is reversed by bad publicity from a drug that can help people, but was used too regularly as an easy option. We live in an age of immediacy, people are used to easy solutions, but medical knowledge is a constantly developing and evolving beast. Ten years ago the notion that Prozac could increase suicidal behaviour was treated as a bit of a conspiracy. Now the belief holds traction with a credible portion of the scientific community. Beliefs and attitudes change as new knowledge comes to light. McDowall told me that all facts about the drug as we know them now are “probably not” common knowledge, to a potential patient, who may not even be in an appropriate place to evaluate the facts. It is difficult to find answers to any concrete questions, but the indecision can be best summed up by Naing, who said that: “medicine is an inexact science. The practice of medicine changes. We have to accumulate continuing professional knowledge to keep our license and to stay in touch.”
There are two competing view points, and the thought that anti-depressants may not be the solution for everyone and that something designed to help can harm, is not getting a lot of consideration at the moment. The “only thing we will ever know for sure is what we don’t know”, Niang told me. And he’s right, it is arrogant and foolish to not even consider the other side of the argument on anti-depressants.