Original article no longer available
By Charles Medawar
Friday, Dec 05, 2003
The widespread prescription of drugs for troubled minds has always ended badly, right back to the days of opiates and cocaine, up through bromides, barbiturates, and tranquilizers: all proved to be highly addictive drugs, but only after years of denial did doctors admit that this was so. Now antidepressants — global brands with household names — are the problem. The past decade has seen a three-fold increase in prescriptions. In England, prescriptions of antidepressants now match Valium at its peak in 1979.
It is now clear that today’s antidepressants are not the wonder drugs they were touted as being. The sometimes intolerable withdrawal symptoms that can make it difficult and hazardous to stop taking antidepressants also expose many users to severe and depressing side effects: substantial weight gain, loss of libido and mood changes, to name just the most common complaints. Suspicions about such problems — especially about drug-induced suicidal behavior and sensitization to depression — have been rumbling for years, but searching scientific investigations have only just begun.
An important inquiry set up by the UK’s drug regulators in the middle of this year will soon report its findings. They will no doubt be presented mainly as recommendations for small-print changes in the warnings on drug labels and in the instructions for the drug’s use. This may help, it but won’t address the real issue: how could regulators have allowed this problem to recur after so much bitter experience, and why should they now be allowed to investigate themselves?
On the Richter scale of drug disasters, the looming antidepressant crisis appears to range between seven and 11, where thalidomide rates a 10. Time will tell, but the key point is this: the thalidomide disaster of the 1950s and 1960s happened because there was no independent control of drug safety, whereas the antidepressant crisis has grown under the aegis of an elaborate, expensive and global regulatory system.
The nub of the antidepressant crisis is not that these drugs could do so much harm, but that they were allowed to do so when the precedents were so plain. If and when this crisis is ever properly investigated, it will not so much open a can of pharmacological worms, as expose questions about what medicine is and should be.
These underlying issues seem all the more important because the Internet has for several years been groaning with evidence of the crisis to come. The explosive growth of the Internet introduced completely new opportunities for gathering, presenting and communicating evidence. It broadened and deepened understanding of the problems associated with antidepressants, giving patients a collective voice, as never before.
Previously, drug-safety monitoring relied on occasional adverse reports from health professionals about patients’ reaction to medicines. But this crisis revealed these reports’ fundamental inadequacies, such that users’ experiences with drugs can never credibly be ignored again.
United by the Internet, many thousands of patients from all over the world began to describe experiences with antidepressant drugs and problems brought on by withdrawal that bore little resemblance to the labels’ warnings. The impact of this user intelligence has been profound: this year, one pharmaceutical company revised its estimate for last year of the incidence of withdrawal reactions from 0.2 percent to 25 percent (even as the manufacturer of a similar drug continues to claim that it is “not habit forming” at all).
The antidepressant crisis provides, for the first time, dramatic evidence of the collective value of user reports in understanding drug risk. To be sure, user reports are not “scientific” and most, individually, might seem naive, confused, exaggerated, mistaken and/or just plain self-absorbed. Yet in this case they provided, collectively, more reliable evidence than that reported in numerous controlled clinical trials.
So, now the question is not so much the value of patients’ reports, but the integrity of medical research and the state of science. “Just how tainted has clinical medicine become,” asked an editorial in the British medical journal The Lancet last year; the answer was “heavily and damagingly so.” The duplicity surrounding the marketing of antidepressant drugs underscores just how corrupt the profession has become.
The crisis now unfolding raises broad issues concerning democracy and science, the relationship between risk and benefit, and the conflict between imperatives of trade and health. But one feature above all others captures the underlying problem: the yawning gap between the words of patients who speak their minds and the terminology of producers, experts, and authorities who mince words.
The 1990s saw “depression” formally redefined as a serotonin-deficiency disease and the scourge of millions — which was a convenient and seductive view, but deeply simplistic. The term “drug dependence” was also redefined, to propose that loss of personal autonomy could never arise in a therapeutic setting. The ubiquitous term “discontinuation symptoms” — Orwellian newspeak for withdrawal — seemed to imply that antidepressants carried no risk of dependence.
On the contrary, wishful thinking led experts to adduce “discontinuation symptoms” as evidence of the effectiveness of vital remedies.
Later, suicides became routinely described as “non-accidental overdoses,” and the broad-spectrum term “emotional lability” came into vogue, despite its inability to distinguish between a drug-induced suicide attempt and an outburst of tears.
By contrast, user reports of adverse reactions attempt to describe some human reality, rather than promote images that suit the vested interests involved. In the long run, the antidepressant crisis thus may prove to be a blessing in disguise, but only if it brings about the transparency and intellectual honesty needed to make the medical profession ultimately accountable to the people it claims to serve.
Charles Medawar, a specialist on medical policy and drug safety, is currently a director of a small London-based unit, Social Audit Ltd, mainly funded by the Joseph Rowntree Charitable Trust.