Anatomy of an Epidemic (47 page)

The first time that Jenna had been exposed to a psychiatric drug was when she was in the second grade, and that episode suggested that she would not be a good responder to psychotropics. Up until that time Jenna had been a healthy child, a star on a local swim team; only then she developed seizures, and when she was put on an anticonvulsive agent, she developed severe motor problems, her mother said, in a phone interview. But eventually the seizures went away and once Jenna stopped taking the anticonvulsant, her motor problems disappeared. Jenna took up horseback riding, excelling in show-jumping competition. “She was back to being totally normal,” her mother recalled.

When Jenna entered ninth grade, her mother and stepfather decided to send her to an elite boarding school in Massachusetts, as they didn’t trust the public schools in Tennessee, and it was then that her behavioral and emotional problems began. She was kicked out of that first school and sent to a second one for troubled teens, where she “got into all that Gothic stuff” and began “acting out” sexually, her mother said. Then, on a dare one night, Jenna stole a package of condoms from a drugstore and “freaked out” when she was arrested. Now she was sent to a third boarding school and prescribed Paxil.

“The minute she takes that drug, she starts shaking,” her mother said. “I tell the doctor, ‘Oh my gosh, it is from the medicine.’ The doctor says, ‘Oh no, it’s not the medicine.’ I said, ‘Yes it is.’ We went
from one doctor to another, doing test after test, but they couldn’t find anything and so they kept her on the medications, which made everything worse. They just wouldn’t listen to me.”

In addition to the tremors, Jenna became suicidal while taking Paxil, and soon her life transformed into a psychiatric nightmare. She began cutting herself regularly, and at one point, she used an electric saw to take off the middle finger on her left hand. The Paxil gave way to cocktails of Klonopin, Depakote, Zyprexa, and other medications, and during a nearly four-year stay in a psych hospital, she ended up on a cocktail of fifteen or so drugs, so doped up she didn’t even know where she was. “I don’t know the exact date,” Jenna says, summing up this history, “but slowly my speech and my walking and my balance and the shaking got really bad at that hospital. And they just kept on adding drugs. That’s how f-f-f-fucked up they are.”

Today, Jenna’s psychiatric problems remain severe. On the day we met, her wrist was bandaged, as she had recently tried to cut herself, and thus the medications haven’t been much help in that regard, either. But, she says, “I don’t see anything different happening. I have brought up the issue of taking me off the meds billions of times.”

Before we left our sidewalk table, Chris provided me with the details of Jenna’s daily cocktail: two antidepressants, an antipsychotic, a benzodiazepine, a Parkinson’s medication, and three others for physical problems likely related to the psychiatric drugs. Later, I calculated that even if generics were prescribed whenever possible, she was consuming $800 of medication monthly, or roughly $10,000 annually. She had been on psychiatric medications for twelve years, which meant that her Rx bill for psychiatric medications might already have surpassed $100,000, and given that she will likely remain on the drugs for the rest of her life, this bill could eventually end up well north of $200,000.

“They are making a lot of money on me,” Jenna says. “But these drugs have ruined my life. They make me all f-f-f-fucked up.”

Jenna’s perspective on her care was not an unusual one. Many of the people on SSI and SSDI that I interviewed spoke about how they felt they were caught in the tangles of a business enterprise. “There is a reason we are called
consumers
” was a comment I heard several times. They are right of course that the pharmaceutical companies want to build a market for their products, and when we view the psychopharmacology “revolution” through this prism, as a business enterprise first and a medical enterprise second, we can easily see why psychiatry and the pharmaceutical companies tell the stories they do, and why the studies detailing poor long-term outcomes have been kept from the public. That information would derail a business enterprise that brings profits to so many.

As we saw earlier, during the late 1970s psychiatry was worried about its survival. The public viewed its therapies as “low in efficacy,” and sales of psychiatric drugs were in decline. Then, in what might be called a “rebranding” effort, psychiatry published DSM-III and began telling the public that mental disorders were “real” diseases, just like diabetes and cancer, and that their drugs were chemical antidotes to those diseases, just like “insulin for diabetes.” That story, while it may have been false in kind, created a powerful conceptual framework for selling psychiatric medications of all types. Everyone could understand the chemical-imbalance metaphor, and once the public came to understand that notion, it became relatively simple for pharmaceutical companies and their storytelling allies to build markets for psychiatric drugs of various types. They ran “educational” campaigns to make the public more “aware” of the various disorders the drugs were approved to treat, and, at the same time, they expanded the diagnostic boundaries of mental disorders.

After Prozac was introduced, NIMH’s DART campaign informed the public that depression regularly went “undiagnosed and untreated.” Upjohn partnered with the APA to tell the public that “panic disorder” was a common affliction. In 1990, the NIMH launched its “Decade of the Brain,” telling the public that 20
percent of Americans suffered from mental disorders (and thus might be in need of psychiatric medications). Soon psychiatric groups and others were promoting “screening programs,” which from a business perspective are best described as customer-recruitment efforts. NAMI, for its part, understood that its “educational” efforts served a commercial end, writing in a 2000 document filed with the government that “providers, health plans, and pharmaceutical companies want to grow their markets and to increase their share of the market…. NAMI will cooperate with these entities to grow the market by making persons aware of the issues involving severe brain disorders.”
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The APA is in charge of defining diagnostic categories in our society, and DSM-IV, an 886-page tome published in 1994, listed 297 disorders, 32 more than DSM-III. New and expanded diagnoses invite more people into the psychiatric drugstore, and one of the best examples of this type of market-building occurred in 1998, when GlaxoSmithKline got the FDA to approve Paxil for “social anxiety disorder.” In the past, this might have been perceived as a character trait (shyness), but GlaxoSmithKline hired a PR firm, Cohn & Wolfe, to promote awareness of this newly recognized “disease,” and soon newspapers and television shows were telling of how SAD afflicted 13 percent of the American population, making it “the third most common psychiatric disorder in the United States, after depression and alcoholism.” Those afflicted with this illness, the public learned, were in some ways biologically “allergic to people.”
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Diagnostic changes lay behind the bipolar boom, too. In DSM-III (1980), bipolar illness was identified for the first time (the old manic-depressive cohort was splintered into different groups), and then psychiatry steadily loosened the diagnostic boundaries for this illness, such that today the field talks about bipolar I, bipolar II, and a “bipolarity intermediate between bipolar disorder and normality.” This once rare disease is now said to afflict 1 to 2 percent of the adult population, and if the “intermediate” bipolar folk are counted, 6 percent. As this diagnostic expansion happened, pharmaceutical companies and their allies mounted their usual “educational” campaigns. Abbott Laboratories and NAMI teamed up to promote a “Bipolar Awareness Day;” in 2002, Eli Lilly joined with the Depression
and Bipolar Support Alliance to launch a new online destination,
bipolarawareness.com
. Today many websites offer visitors a quick question-and-answer test to see if they have this illness.

Naturally, pharmaceutical companies want to sell their drugs to people of all ages, and they built the pediatric market for psychotropics step by step. First, in the 1980s, the prescribing of stimulants to “hyperactive” children took off. Next, in the early 1990s, psychiatrists began regularly prescribing SSRIs to teenagers. But that meant prepubertal children weren’t being prescribed these new wonder drugs, and in 1997, the
Wall Street Journal
reported that the manufacturers of SSRIs were “taking aim at a controversial new market: children.” The drug firms were “preparing their medications in easy-to-swallow forms that will be more palatable to even the youngest tykes,” the newspaper said, with Eli Lilly formulating a “minty liquid” Prozac for the tots to down.
⁴
The
New York Times
, in its coverage of this initiative, explained quite clearly what was driving it: “The adult market for [SSRIs] has become saturated…. The companies are looking for expanded markets.”
⁵
Psychiatry quickly provided a medical cover for this marketing effort, with the American Academy of Child and Adolescent Psychiatry announcing that 5 percent of all children in the United States were clinically depressed. “Many of these young patients now are inadequately treated, experts say, often leading to long-term emotional and behavioral problems, drug abuse, or even suicide,” the
Wall Street Journal
reported.
⁶

The creation of the “juvenile bipolar” market was a bit more complicated. Prior to the 1990s, psychiatry thought that bipolar illness simply didn’t occur in prepubertal children, or was extremely rare. But children and teenagers prescribed stimulants and antidepressants often suffered manic episodes, and thus pediatricians and psychiatrists began to see more youth with “bipolar” symptoms. At the same time, once Janssen and Eli Lilly brought their atypical antipsychotics to market, they were looking for a way to sell those drugs to children, and during the mid-1990s, Joseph Biederman at Massachusetts General Hospital in Boston provided the diagnostic framework that made that possible. In 2009, while being deposed in a legal case, he explained his handiwork.

All psychiatric diagnoses, he said, “are subjective in children and in adults.” As such, he and his colleagues decided that children who in the past had been seen as having pronounced behavioral problems should instead be diagnosed with juvenile bipolar illness. “The conditions that we see in front of us are reconceptualized,” Biederman testified. “These children have been called in the past conduct disorder, oppositional-defiant disorder. It’s not that these children did not exist, they were just under different names.”
⁷
Biederman and his colleagues decided that “severe irritability” or “affective storms” would be the telltale signs of juvenile bipolar disorder, and with this new diagnostic criteria in hand, they announced in 1996 that many children diagnosed with ADHD were in fact “bipolar” or else “comorbid” for both illnesses.
⁸
The illness was a “much more common condition than was previously thought,” often appearing when children were only four or five years old, Biederman said.
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9
Soon parents in the United States were reading newspaper articles about this newly recognized illness and buying
The Bipolar Child
, a book published by Random House in 2000. Child psychiatrists, meanwhile, began treating it with atypical antipsychotics.

That was the marketing machinery that lured more and more Americans into the psychiatric drugstore. As new drugs were brought to market, disease “awareness” campaigns were conducted and diagnostic categories were expanded. Now, once a business gets a customer into its store, it wants to keep that customer and get that customer to buy multiple products, and that’s when the psychiatric “drug trap” kicks in.

The “broken brain” story helps with customer retention, of course, for if a person suffers a “chemical imbalance,” then it makes sense that he or she will have to take the medication to correct it indefinitely, like “insulin for diabetes.” But more important, the drugs
create
chemical imbalances in the brain, and this helps turn a first-time customer into a long-term user, and often into a buyer of multiple drugs. The patient’s brain adapts to the first drug, and that makes it difficult to go off the medication. The store’s exit door is hard to squeeze through, so to speak. At the same time, since psychiatric drugs perturb normal function, they regularly cause physical and psychiatric problems, and this greases the path to polypharmacy. The hyperactive child is put on a stimulant that rouses him during the day; at night he needs a sleeping pill to go to sleep. An atypical causes people to feel depressed and lethargic; psychiatrists may prescribe an antidepressant to treat that problem. Conversely, an antidepressant may stir a bout of mania; in that case an atypical antipsychotic may be prescribed to tamp down the mania. The first drug triggers a need for a second, and so on.

Eli Lilly even capitalized on this fact when it brought Zyprexa to market. As it well knew, Prozac and other SSRIs could trigger manic episodes, and so it instructed its sales representatives to tell psychiatrists that Zyprexa “is a great mood stabilizer, especially for patients whose symptoms were aggravated by an SSRI.”
¹⁰
In essence, Eli Lilly was telling doctors to prescribe its second drug to fix the psychiatric problems caused by its first one. We can also see this cascading effect operating at a societal level. The SSRIs came to market and suddenly bipolar patients were cropping up everywhere, and then this new group of patients provided a market for the atypicals.
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All of this has produced a growth industry of impressive dimensions. In 1985, outpatient sales of antidepressants and antipsychotics in the United States amounted to $503 million.
¹¹
Twenty-three years later, U.S. sales of antidepressants and anti psychotics reached $24.2 billion, nearly a fiftyfold increase. Anti psychotics—a class of drugs previously seen as extremely problematic in kind, useful only in severely ill patients—were the top revenue-producing class of drugs in 2008, ahead even of the cholesterol-lowering agents.
¹²
Total sales of all psychotropic drugs in 2008 topped $40 billion. Today—and this shows how crowded the drugstore has become—one in every eight Americans takes a psychiatric drug on a regular basis.
¹³