Opinions - Talking Back to Prozac (Fluoxetine)

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[top]Talking Back to Prozac

By Frederick C. Crews

New York Review of Books

Volume 54, Number 19 · December 6, 2007

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. 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.

This article reviews the books:

The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder,
by Allan V. Horwitz and Jerome C. Wakefield

Oxford University Press, 287 pp., $29.95

Shyness: How Normal Behavior Became a Sickness,
by Christopher Lane

Yale University Press, 263 pp., $27.50

Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression, by David Healy

New York University Press, 351 pp., $18.95

Continued