Wear Clean Draws  (because there’s 5 million ways to kill a ceo)

huh. reading stuff that susie bright linked to, i came across David Healey’s Let them Eat Prozac. While I find Healey’s writing more than a little confusing — he’s not a good writer — I could help but remain riveted.

For one, his testimony in the trial against Eli Lilly over the murder/suicide of David Forsythe and his wife, in Hawaii, revealed that the claim that suicide and suicidal ideation as a result of taking SSRI’s is not very likely due to the disease. What I mean is, the objection is that what happens is that people who are very depressed, take the SSRI, and they start to become well, they start to become destablized by being well and/or they become capable of more than being wholly immobilized and are more capable of acting on suicidal feelings.

In either case, this explanation turns out to be wrong according to David Healy:

“As with Zelmid before it, there was a natural interest on the part of clinicians to try fluvoxamine. In the 1980s, this meant that the first patients to get a new antidepressant would be patients who were hospitalized with depression, who seemed unresponsive to other therapies. This is not a promising patient group on whom to try out a new drug. It has since become clear that SSRIs do not do very well for in-patient depressions. This lack of response along with a severe nausea in a significant number of patients led to the clinical impression that fluvoxamine was unlikely to make significant inroads into the antidepressant market. It never did.”

http://www.healyprozac.com/Book/Introduction.doc

In general, SSRIs don’t work very well for people hospitalized with major depression so the idea that they are too immobilized to act on it is wrong. But even more damning is the evidence that Eli Lilly and other pharmaceutical companies tried to suppress: when SSRIs are given to people who are not depressed, to treat them for other things such as obesity, it’s among those people who there is evidence of increased suicidal ideation and increased suicide.

Additionally, since SSRIs don’t work on people hospitalized with depression, they are given to people with milder forms of depression. According to Healey, it’s people with the mildest forms of depression who suffer the greatest risk of responding with greater incidences of suicidal ideation and suicide.

Healey also has some fascinating analysis of pharmacology and politics, and not in some facile way but in a rather more philosophical way. In this great lecture he’s given, and one for which he was denied a position and over which he sued for academic freedom issues, he talks about the ways that drugs have been categories, politically: as ‘good’ drugs that help restore social order and ‘bad’ drugs that help undermine social order.

One of the indicators for a ‘bad’ drug has been ‘dependence’. I think about this because Gary mentioned what happens to him when he tries to get off his meds: he feels like spiders are crawling all over him. Apparently SSRIs are notorious for this problem: people become dependent on them and go through terrible withdrawal symptoms. Read Healey on this, he explains all of it in various chapters from Let Them Eat Prozac.

Basically, an SSRI is a foreign element introduced to the body. It’s not a subsitute for something that exists. When you remove it, you destabilize the body and ithas to react to compensate for the loss. Healey describes it much better:

“And indeed the SSRIs are not addictive in the sense that they will transform someone into a junkie, who is likely to mortgage their livelihood and their future for an ongoing supply of drugs. They do not lead to a life of crime or dissolution. But this does not mean that the antidepressants – at least the SSRIs - don’t produce significant dependence. SSRI dependence may in fact be more common and serious than benzodiazepine dependence. It may not be possible for many people to get off treatment without great difficulties. In lay terms, you can just as easily become hooked to SSRIs as to benzodiazepines.

Far from the problem with SSRIs being simply one of dependence that emerges on withdrawal from the drugs, these drugs produce what are more appropriately termed stress syndromes. The SSRIs are alien chemicals rather than replacement chemicals, like insulin or thyroid hormone. As such, they are a brain stressor. The consequences of this stress can be apparent in some individuals when the stress is withdrawn and the system attempts to get back into equilibrium. But in others the stresses can be visible during the course of treatment. With the SSRIs, a problem called poop-out had been noted from early on . Poop-out refers to a phenomenon where after time the drugs appear to lose potency and individuals have to increase the doses with successive increases re-instituting response in some cases .

As with many of the other problems with the SSRIs, this phenomenon first came to light in Internet chat rooms rather than through physicians being informed by companies of the existence of a problem . Because companies denied the existence of the problem, they could not advise on the best means of managing it. Clinicians were left to their own devices. This is hardly the kind of partnership that is supposed to characterize prescription-only arrangements.

The Paxil dependence story in fact opened up one of the great mysteries in psychopharmacology, a mystery that is yet to be resolved. In the early 1960s discontinuation problems with antidepressants and antipsychotics had been widely reported. The issue of dependence on these drugs was debated in international psychopharmacology meetings, and agreement was reached that these drugs produced dependence of a different type to that produced by cocaine and the amphetamines on one hand or the opiates, alcohol and barbiturates on the other. Recognition of these dependence syndromes vanished shortly after, however . Why?

To appreciate this needs some understanding of the history of addiction. Up until the 1950s, addiction was seen largely as a personality disorder. It was only in the 1940s that the work of Abe Wikler and Harris Isbell put the role of withdrawal syndromes to alcohol, opiates, and barbiturates firmly on the map as a cause of dependence. In the 1960s, it was discovered that cocaine and the amphetamines were drugs that animals could be taught to self-administer. The animals apparently developed cravings for these drugs. These drugs had an abuse liability that they in fact shared with alcohol, the barbiturates and the opiates. These discoveries gave rise to the notion of drug dependence and they underpinned some of the definitions of addiction and dependence that were adopted in the 1970s. But according to these criteria, the benzodiazepines were not drugs of dependence as their abuse liability was low in animal models. This was part of the reason the psychiatric establishment reacted with disbelief in the face of criticisms from patient groups and others of therapeutic drug dependence.

However in the 1960s, there had also been a clear recognition that antidepressants and antipsychotics, which did not cause cravings or tolerance, could cause dependence. The recognition of this therapeutic drug dependence vanished by 1970 . The eclipse of therapeutic drug dependence owes a great deal to the growing use of LSD and the hallucinogens as well as opiates and amphetamine in the 1960s by middle-class and student populations. This new use of psychotropic substances contributed significantly to the student revolutions of the late 1960s and the development of anti-psychiatry, which put a range of physical therapies, including ECT and the antipsychotics in the firing line.

Psychiatry somehow had to work out a system to accommodate the fact that all psychotropic drugs ran the risk of producing dependence but yet some drugs were going to be used therapeutically. Few would argue that there is a God-given order to the universe so that only “bad” drugs cause problems to people. But this is exactly what mainstream clinical practice now argues in practice. Neither DSM-III nor DSM-IV recognizes the possibility of therapeutic drug dependence. Similarly we have difficulties embracing the possibility that “Good” drugs might trigger suicide, but no difficulties in accepting that LSD might do this — even though there is an overlap between the actions of both LSD and cocaine on the serotonin system on the one side and the SSRIs on the other.

A key feature of the Paxil story is that ultimately dependence on SSRIs is more likely to bring this group of drugs into public disrepute rather than the issue of SSRIs and suicide. Suicide is something that anyone contemplating using an SSRI finds hard to envisage a drug causing, but we can readily envisage getting hooked to a drug and we dread the possibility.