Insane Medicine, Chapter 5: The Manufacture of Childhood Depression (Part 2)!!

Editor’s Note: Over the next several months, Mad in America will publish a serialized version of Sami Timimi’s book, Insane Medicine. In Part 1 of Chapter 5, he explored the “McDonaldisation” of growing up—how changing attitudes toward childhood have led to an epidemic of childhood “depression.” This week, he discusses the evidence base for “antidepressant” medications for children and adolescents. Each Monday, a new section of the book will be published, and all chapters will be archived here.

The selling of a panacea
Modern medicine has had some amazing successes in alleviating unnecessary suffering and reducing morbidity. Some diseases, like smallpox, have been completely eradicated; others that would have quickly killed most people—from bacterial pneumonia to Type 1 diabetes—can now be cured or effectively managed. But such progress awakens deeper, childish desires and fantasies that all suffering or unpleasant experiences have no value and are simply things we could and should eliminate from human experience.

Ivan Illich’s classic 1974 book Medical Nemesis warned us that medicalisation changes our relationship to hardship and pain and in ways that may ultimately hinder our health and wellbeing. With the advent of various types of pain-killing technologies, we start to imagine that pain and suffering can be removed from the long list of inevitable experiences humans have to comprehend and deal with.

The act of suffering had previously been shaped by culture into something with meaning, which can be stated and shared. Medicalisation led to suffering becoming detached from its cultural and social moorings.

For Illich, medical “civilisation” replaces culturally determined competence in suffering with a growing demand by each individual for the institutional management of their pain. Pain then just becomes an item on a list of complaints—things that we should not have to engage with.

As a result, a new kind of horror emerges. While the experience is still pain, the impact on our emotions has been amplified as this is now felt to be something valueless, opaque, and impersonal. By becoming unnecessary and avoidable, pain becomes unbearable. It has become meaningless, question-less torture.

The loss of meaning and value in pain can change your relationship to it and how you feel about that and other types of suffering. There is something even more sinister that lurks in the idea that mental suffering is valueless, meaningless, and something that can be simply expunged and eliminated by technical means. Unhappiness and mental pain are universal experiences. Yes, they can be devastating, cause significant impairment, and many can benefit for a range of supports, professional and non-professional, to help guide them through those darker times. But it’s not meaningless experience. We have to story it in some way.

When we narrate that experience as a chemical imbalance in the brain that erupts out of our biology and over which we have no control, we are not stating a medical fact, we are giving the experience a meaning. The meanings we give have consequences.

What if narrating suffering as an illness, something valueless, impersonal, with nothing to teach us, causes mental suffering to become even worse as it transforms into meaningless torture that keeps returning? What if this story makes our relationship to suffering primarily antagonistic, something to be feared, controlled, and suppressed, rather than engaged with in some way?

As we expand the medicalisation of pain into all mental suffering, so certain brands present themselves as ideal vehicles to culturally McDonaldise the process of wiping away suffering. Depression has become big business for the pharmaceutical industry, psychiatrists, psychologists, therapists, and a whole host of other players. It has been promoted as a lucrative brand for several decades now (although I don’t doubt most who promote it do so out of a genuine desire to help people).

The promotion of branded depression really took off after the selective serotonin reuptake inhibitor (SSRI) Prozac (the generic name is fluoxetine), first introduced in 1988, was marketed by Eli Lilly (the drug company that manufactured it) as a new antidepressant with few side effects, and promoted with the slogan “happiness in a blister pack.”

Eli Lilly first synthesised the drug that eventually became Prozac in 1971 and originally saw an entirely different future for it. It was first tested as a treatment for high blood pressure, which worked in some animals but not in humans. They then tried it as an anti-obesity agent, but this didn’t work either. When tested on psychotic patients and those hospitalised with depression, it had no obvious benefit, with a number of patients getting worse. Finally, Eli Lilly tested it on patients thought to have “mild depression.” Five recruits tried it and all five felt better after taking it. The rest, as they say, is history.

Prozac soon became a blockbuster drug that was elevated to celebrity status by books like Peter Kramer’s Listening to Prozac, where he spoke about how some of his patients became “better than well” after taking it. National campaigns (supported by Eli Lilly) alerted doctors and the public to the dangers of depression and funded the printing of millions of brochures and posters on depression. Prozac was pushed as entirely safe, non-addictive and with few side effects—a panacea.

Other drug companies soon produced their own SSRI drugs, as the potential for enormous profit became apparent. Most of the marketing effort went into promoting “depression” as a clinical condition. The resulting educational campaigns, often supported by and in collaboration with psychiatric institutions, resulted in an extraordinary expansion in the numbers of people receiving a diagnosis of depression and being subsequently prescribed a “safe, non-addictive” SSRI “antidepressant.”

For example, between 1992 and 1996, the Royal College of Psychiatrists and the Royal College of General Practitioners in the UK promoted the “Defeat Depression Campaign.” Using medicalised language, it sought to educate General Practitioners (GPs—this is the title for UK primary care doctors) and the general public to better recognise and manage depression. The campaign included use of surveys that found that the public seemed to be sympathetic to those with depression but reluctant to consult about it.

85% believed counselling to be effective but were against antidepressants and 78% regarded antidepressants as addictive (which, we now know, is in fact the case). At this time, most patients treated with antidepressants in primary care abandoned taking them due to fear of dependence.

One of the main messages that doctors were encouraged to give to patients was to educate them that dependence was not a problem. Prescriptions soon rocketed. In the UK, between 1991 and 2001, antidepressant prescriptions rose from 9 million to 24 million prescriptions a year.

The public were thus brainwashed into believing depression was a disease like any other medical disease, that chemical imbalances caused depression, that GPs were missing and not diagnosing depression frequently enough, and that treatment with medication was safe and effective. The fashion to explain our mental states as being the result of neurochemical goings on took root, opening the way for all types of mental suffering to become targets for a pill.

The culture of an ill for every pill grew, promoting the language of psychiatric disorders and a corruption of psychiatry through collusion with the pharmaceutical industry. This influenced GPs’ prescribing habits and general public beliefs about the nature of mental functioning and how to make sense of all sorts of mental pain and discomfort.

The growth of the popularity of the concept of childhood depression—from a rare to a common diagnosis that is similar to adult depression and amenable to individualised pharmaceutical and psychological treatments—began in the early 1990s and accelerated rapidly over the next decade.

A shift in theory (and consequently, practice) took place as influential academics claimed that childhood depression was more common than previously thought (quoting figures such as 8-20% of children and adolescents), resembled adult depression, was a precursor to adult depression, was amenable to treatment with antidepressants, and that early intervention was needed to prevent future problems.

This happened before any studies that showed benefit of “antidepressants” in the under-18s were published. Thus, prescriptions of drugs marketed as “antidepressants” began to made to youth under the assumption that adolescents experience this disease called “depression” in a similar way to adults and that they respond to the same treatments.

Psychiatrists in the US started to experiment with prescribing SSRIs to children, spurring drug companies to manufacture and promote products targeted at the young, such as a liquid version of Prozac being manufactured to enable lower doses than the standard 20 milligram capsule to be prescribed.

The UK soon caught up with this new trend. Between 1992 and 2001, prescriptions of SSRIs for under-18s increased tenfold, despite the fact that none had a licence for use in children. But potential disaster was about to strike for the reputation of SSRIs and in particular for its use in young people.

Panacea questioned
In the late 1990s and early 2000s, the first studies, all pharmaceutical industry sponsored, of SSRIs in under-18s were published. They appeared to support the new practice of using this medication, with the authors concluding that these drugs were safe and effective in this age group.

A classic example of how results were “spun” to hide the real findings that these studies were uncovering was the study of the SSRI paroxetine (often referred to as Study 329) that was funded by SmithKline Beecham (SKB; subsequently GlaxoSmithKline, GSK) and published in 2001. The original study concluded that “Paroxetine is generally well tolerated and effective for major depression in adolescents.”

In a unique subsequent re-analysis of this trial (unique because it’s so rare to be able to get hold of original trial data held by drug companies), researchers using the data from the original Study 329 found that paroxetine was in fact no better at treating “major depression in adolescents” than placebo, but there were substantially more harms in the group taking paroxetine—the opposite of what the original Study 329 trial had reported.

The false claims of safety and efficacy from the emerging literature on antidepressants in the young added momentum to the increasing rates of prescribing of antidepressants to under-18s that has largely continued to this day, with one important exception.

In 2002 in the UK, the BBC aired a prime-time documentary programme (known as Panorama) about the SSRI antidepressant Seroxat, examining the false marketing, addictive potential, and the evidence suggesting that it caused increased suicidality, particularly in young people. After the programme aired, the BBC received thousands of calls from viewers reporting similar reactions to that described in the programme (agitation, aggression, and suicidal thoughts). The ensuing media coverage forced the UK Committee on Safety in Medicine (CSM) to investigate these alleged dangers.

In December 2003, the UK CSM issued new guidance to UK doctors stating that SSRI anti-depressants (bar one—fluoxetine) should not be prescribed to the under-18 age group, as available evidence suggested they are not effective and run the risk of serious side effects such as increased suicidality. Several reviews around that time found disturbing shortcomings in the methods and reporting of trials of these newer antidepressants in young people an