01 July 2009

the elasticity of psychiatric diagnosis

Whatever the merits of the SSRIs, they have been among the most heavily promoted drugs of the past decade. The manufacturers of anti-depressants have taken full advantage of the relaxation of U.S. FDA restrictions on prescription drug advertising in 1997. In 2000 Paxil was the fourth most heavily promoted prescription drug in America, with $91.8 million in direct-to-consumer spending. Eli Lilly spent $37.7 million that same year advertising fluoxetine—$23.3 million as Prozac and $14.4 million as Sarafem. To put these figures in context: GlaxoSmithKline spent more money advertising Paxil than Nike spent advertising its top shoes. Direct-to-consumer advertising clearly works. From 1999 to 2000, antidepressants saw a 20.9 percent increase in sales to a figure of $10.4 billion, maintaining their position as the best-selling category of drugs in the United States. In 2000 Prozac was America's fourth most prescribed drug: Zoloft was number seven, and Paxil was number eight.
  Of course, the SSRIs could not have achieved such spectacular success if they did not work for some patients. Yet an equally important reason behind the success of psychoactive drugs in general, and the SSRIs in particular, is the elasticity of psychiatric diagnosis. Categories of "mental disorders" are in constant flux, and they often expand dramatically once a new treatment is marketed. For example, social anxiety disorder—the fear of being embarrassed or humiliated in public—was considered a rare disorder until physicians began treating it with Nardil (phenelzine) in the mid-1980s and then, later, with SSRIs such as Paxil. Today social phobia is often described as the third most common mental disorder in the United States. Similar stories can be told for obsessive-compulsive disorder and panic disorder... As David Healy has pointed out, the key to selling psychoactive drugs is to sell mental disorders.
  But to sell a mental disorder, you must first capture it and make it your own. A drug manufacturer is not allowed to promote a product for a specific disorder until that product has FDA approval. As a result, SSRI manufacturers jockey aggressively among themselves to claim new pieces of the mental disorder market. While the FDA has approved all six SSRIs on the market for depression, Paxil was until recently the only drug approved for social anxiety disorder. (In 2003 it was joined by Zoloft and Effexor.) All of the SSRIs except Celexa and Effexor have been approved for obsessive-compulsive disorder, but only Effexor and Paxil have been approved for generalized anxiety disorder. Zoloft and Paxil have claimed panic disorder and posttraumatic stress disorder, but only Prozac has been approved for bulimia. Eli Lilly's patent on Prozac expired in 2001, but Lilly has begun marketing the same drug under a different name, Sarafem, as a treatment for "premenstrual dysphoric disorder".
  Conventional wisdom attributes the spectacular success of the SSRIs to their relative absence of side effects. For instance, monoamine oxidase inhibitors, an alternative type of antidepressant, can be dangerous without strict dietary restrictions, and people taking the longer established tricyclic antidepressants often complain of drowsiness, dizziness, dry mouth, or constipation. Prozac and the other SSRIs initially appeared much less burdensome. Another significant reason for the success of the SSRIs lies in their ease of use. "One pill a day forever," says Jonathan Cole. "Fluoxetine at one pill a day is the ideal primary care physician's drug." Today, in fact, it is no longer even one pill a day. Prozac Weekly is a once-a-week version of Prozac that Lilly has marketed using coupons in newspapers and magazines. The one-pill strategy has clearly worked, whether the one pill is taken daily or weekly. It has been estimated that as much as 70 percent of the SSRIs is prescribed not by psychiatrists but by primary care physicians.
  ... In bioethics the conventional response to the phenomenon that Kramer called cosmetic psychopharmacology" has been to classify it as enhancement technology. The distinction between enhancement and treatment had gained currency during the ethical debate over gene therapy in the late 1980s and early 1990s. Many people were eager to press a research agenda into the therapeutic uses of genetic technology for conditions such as adenosine deficiency or cystic fibrosis but worried about the use of such technologies for eugenic purposes. Since then, bioethicists have used the term "enhancement technology" as a shorthand for all sorts of technologies whose uses go beyond the strictly medical, from synthetic growth hormone for short boys to Botox injections for aging women. The unstated assumption behind the term has been that there is a morally important distinction between enhancement and treatment. Treating illness, it has been argued, is an essential part of medical practice. Doctors have an obligation to treat sick people. Enhancements, in contrast, are seen as extras—ethically acceptable, perhaps, but not something that a doctor has any particular obligation to provide or that a liberal society has an obligation to fund.
  Yet the distinction between treatment and enhancement turns out to be much more elusive than it first appears, especially in psychiatry. Where is the line between psychopathology and social deviance, perversion, or eccentricity? When does shyness turn into social phobia, or melancholy into depression? The problem is complicated still further by the fact that so little is known about the causes or pathophysiology of mental disorders, or even about how chemical treatments for these mental disorders work. Philosophers have traditionally argued that illness is a departure from species-typical human functioning, but that definition offers us little guidance when the subject turns to the human mind and human behavior. What kind of behavior is typical of Homo sapiens?
  It might be better to ask, What should we make of the social place that the SSRIs have come to occupy? Every culture has its own socially prescribed psychoactive substances, from peyote, kava, and betel nuts to alcohol, caffeine, and nicotine. But with the SSRIs, the gate to the drug is guarded by doctors, and the passport for access is the diagnosis of mental disorder. Unlike alcohol, which is dispensed in bars and liquor stores, or caffeine, which is dispensed at Starbucks and Unitarian churches, SSRIs are dispensed at doctor's offices and pharmacies. It is the social place occupied by SSRIs that has produced the ambivalence that many of us feel about their popularity. Unlike bartenders and espresso baristas, doctors have not generally thought of their job as making well people feel better than well. But that might change.

Carl Elliott, Prozac as a Way of Life (2004: 4-7)