Book Review: Victoria Times Colonist

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When sickness is profitable, there's a problem
by Penny Draper

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Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients by Ray Moynihan and Alan Cassels; Greystone Books, 241 pages, $32.95

Feeling fatigued? Stressed? Anxious? Chances are there is a disease specially designed to fit your symptoms. And there's somebody out there who will sell you the drug to go with it.

Selling Sickness, by Ray Moynihan and Alan Cassels, is a meticulous study of the methods used by big drug companies to market diseases and sell them to healthy people. It's a scary book. The authors use common conditions such as high cholesterol, high blood pressure and osteoporosis to describe the techniques used by pharmaceutical companies to sell their wares to an ever-growing segment of the population. Whether they are selling drugs or fear is debatable; the only surety is that when healthy people are turned into patients, huge profits can be made.

The book is divided into 10 chapters, each devoted to a "condition," which is then attached to a marketing scheme. The section on high cholesterol, for instance, focuses on the conflict of interest that exists between the drug companies, the doctors and the organizations responsible for drug safety.

The section on social anxiety disorder (sometimes known as shyness) reflects upon the ethics of positioning a "neglected disorder" in the marketplace to create a demand even before the drug treatment is approved for use, and certainly before the addictive properties of the drug are publicly known.

In another chapter, menopause ceases to be part of the natural aging process and becomes a curable deficiency disease.

Other chapters talk about the use of paid celebrities to popularize disease, the invention and branding of diseases, flawed science, suppressed reports, statistical gimmicks, lifestyle drugs and even "astro-turfing," which is described as the creation of fake grassroots movements.

The authors prevent the book from becoming a horror story by asserting that most of the drugs profiled do indeed help some people. But the same drugs can become dangerous when prescribed to people who don't need them. Are drug companies filling "an unmet need" or "meeting an un-need"?

When faced with the fact that the United States spends $25 billion annually on drug marketing, one has to wonder what else that money could be doing.

One of the most interesting aspects of this book is its Canadian perspective. Alan Cassels is a drug policy researcher at the University of Victoria. He interprets the largely U.S.-based information, explaining the potential consequences here at home and raising questions like the potential effect over-prescribing has on a public health care system.

At times the book becomes repetitious, each chapter offering still more examples of the same nasty business. There are numerous citations, with no less than 40 pages of footnotes. For those who generally avoid the small print, be aware that in this book it's fascinating and well worth the effort. Check out some of the websites, links and articles listed in the footnotes and the depth and breadth of the research becomes evident.

The book may look like a textbook, but it reads easily.

Selling Sickness is "offered as part of an ongoing conversation ... to promote a more rational and informed public debate about human health...." In that it succeeds. No answers to the problem of big pharma are offered. But good questions are raised, questions I'll be asking when I next visit the doctor.

Penny Draper is a Victoria writer.

OTHER BOOKS OF INTEREST

Bitter Pills: Inside the Hazardous World of Legal Drugs by Stephen Fried; Bantam; $21

Journalist Stephen Fried's investigation of the international pharmaceutical industry is a personal take on the issue, begun after his wife had a severe reaction to a new antibiotic. It includes an appendix of adverse drug reactions.

Profit is Not the Cure: A Citizen's Guide to Saving Medicare by Maude Barlow; McClelland & Stewart; $21.99

Barlow raises the issue of medical profit as part of the debate over private/public health care systems.

Why We Get Sick by Randolph M. Nesse and George Williams; Vintage; $21

Nesse and Williams's older but still interesting book explores why humans are vulnerable to disease from a Darwinian point of view. He postulates that knowing why we become ill could help us decide if a pill will help -- or hinder -- our recovery

The marketing of Depession: Montreal Gazette

Women rely more on antidepressants, report finds
Prescriptions up 73 per cent in 4 years. Researcher blames increased
marketing of new drugs for emotional disorders

CHARLIE FIDELMAN
The Gazette
Tuesday, November 22, 2005

A majority of Canadian women seeking medical help for emotional problems
are leaving their doctor's office with a prescription for an antidepressant, a new study shows.

"Women are prescribed twice as many psychotropic drugs as men," Vancouver-based health policy researcher Jane Currie said yesterday. "Clinical trials results show these drugs have risks and we don't know what the long-term effects are."

A new class of drugs called selective serotonin reuptake inhibitors are being sold for a wide range of symptoms from anxiety, panic, shyness and insomnia to premenstrual syndrome and compulsive shopping, among other complaints.

Prescriptions jumped to 15.6 million in 2003, up from nearly 9 million in 1999, making depression the fastest-rising diagnosis in doctors' offices.

Two-thirds of users are women, Currie pointed out.

"The prevalence has skyrocketed," said Currie, who draws a link between an epidemic rise in emotional disorders and the marketing of drugs designed to treat these conditions, which are increasingly understood as "a biological phenomenon."

"It's a strange correlation that this has happened since the drugs have come on the market," Currie said, starting with the popular Prozac in the 1980s.

Women and Health Protection, a national working group funded by Health Canada, commissioned the study, titled the Marketization of Depression: Prescribing SSRI Antidepressants to women.

"There's a strong concern that more and more women are being put on them for reasons that are questionable and it's not the best use of health-care dollars," the group's co-ordinator, Anne Rochon Ford, said.

Widespread use of antidepressants among women reflects the fact that more women than men use the medical system.

That's the classic but cliche view that "women go to their doctors and men drink," Rochon said, when the problem is what is being classified as depression.

"The definition of depression is an elastic thing that has expanded to ridiculous proportions," Rochon said. "We've become a nation that pops a pill for just about anything."

Like Valium and an earlier generation of antidepressants, these drugs have always been heavily prescribed to women, Shree Mulay, director of the McGill Centre for Research and Teaching on Women, said.

"We have every reason to be concerned," Mulay said. Not only are "social problems being treated with medicine, but there's the question of (drug addiction) and side effects."

Health advocates say that non-drug therapies - exercise, nutrition counselling, support and psychotherapy - may be more effective treatment than drugs.

It's not one-size-fits-all in depression, said Remi Quirion, head of the Douglas Hospital Research Centre in Verdun.

"I'm totally convinced the increase in diagnosis is because there's less and less stigma associated with depression and other forms of mental illness," Quirion said. "Depression is a brain disorder that can be treated with SSRI or with psychotherapy, but it must be treated.

"I think it was vastly underdiagnosed before," he added.

But Alan Cassels, drug policy researcher at the University of Victoria and co-author of Selling Sickness, How the World's Biggest Pharmaceutical Companies are Turning Us All Into Patients, said the impact of marketing on therapy is undeniable.

Many people lead hectic, stressful, difficult lives, juggling careers, caring for children and aging parents, Cassels said.

"But does that mean you have a serotonin imbalance in the community? Instead of changing the social environment, we are modifying the chemical environment with drugs."

For Currie's report on the web: www.whp-apsf.ca/en/index.html

cfidelman@thegazette.canwest.com

(c) The Gazette (Montreal) 2005

Pharmaceuticals and the push to pop: Ottawa Citizen

Shelley Page

A new book argues that drug companies are redefining what it means to be 'healthy,' turning us all into patients and pilltakers

The big guns of cardiology met this week at the American Heart Association and discussed the future of statins, cholesterol- lowering drugs that are the bestselling pills on the planet. Studies released there suggest that while statins have worked well in fighting bad cholesterol, known as LDL, beyond a certain point the benefits may be slim. Experts suggested drug companies should focus on finding drugs to push up good cholesterol, HDL.

If LDL encourages dangerous plaque to build up and clog artery walls, HDL clears away the plaque. What if a new class of drugs could increase the so-called "good" cholesterol?

The question, posed to a new generation of researchers, should be greeted with some skepticism. Reducing heart attacks and heart disease is crucial, of course. But while statins were becoming the most popular drugs in history, pharmaceutical firms were changing our very definitions of health. Almost at once, people formerly considered healthy were popping one pill or another.

In fact, the authors of a new book titled Selling Sickness argue that drug companies are turning all of us into patients. So while the cardiologists were meeting in Dallas, Alan Cassels and Roy Moynihan were voicing their concerns about the ways drug companies are widening the net of illness, until formerly healthy people have been redefined as sick.

Mr. Cassels, a drug policy researcher at the University of Victoria, and Mr. Moynihan, an Australian health-care journalist, focus on the push to make people pop statins, which generate revenues of more than $25 billion a year for their manufacturers. Canadians gobbled up $1.6 billion worth of statins last year alone.

In 2003, for example, AstraZeneca was poised to launch Crestor, its newest cholesterol-lowering drug. It was a controversial announcement because the drug was said to have double the side- effects of other such drugs. Still, fortune seemed to smile on the big pharmaceutical company.

Dr. Bryan Brewer, a giant in the cholesterol field, was raving about the drug. The senior official with the publicly funded National Institutes of Health told a meeting of the American Health Association that the drug was safe and effective.

His comments were later published in a special supplement of the American Journal of Cardiology, a journal released just as Crestor hit the U.S. market.

The authors question Dr. Brewer's ties to AstraZeneca. Turns out he was one of AstraZeneca's paid speakers. Not only was his seminar and journal supplement financed by AstraZeneca, "so too was Dr. Brewer, though his links were not disclosed in his article in the journal supplement."

Congress hearings would eventually reveal Dr. Brewer received $200,000 U.S. a year from "outside private interests including drug companies, while holding down his position as branch chief at the government's NIH," write the authors.

Before 1987, there wasn't a single statin on the market. Then Merck launched Mevacor, which was seen as a valuable option for people with heart disease. Since then, more and more statins have been developed, including Pfizer's Lipitor, the world's top-selling prescription drug -- ever.

The authors show how the definition of high cholesterol has been regularly broadened to relabel more and more healthy people as sick, thus creating a broader group of patients who could be targeted with drug therapy.

It's certainly possible that, in fact, more people require treatment than was originally thought. But the authors don't think so, and neither do a growing chorus of independent health-care research groups.

According to cholesterol guidelines from the 1990s, 13 million Americans might have required statin treatment. In 2001, a new panel rewrote the guidelines and the number increased to 36 million.

Then in 2004, yet another panel broadened the guidelines to say 40 million Americans would benefit from taking statins. While these new guidelines were being redrawn, the U.S. -- where, unlike Canada, direct-to-consumer advertising is permitted -- was bombarded with advertising that without statins healthy Americans could die of heart attacks.

Many of those who expanded the guidelines were cosy with the drug companies that would benefit. In 2001, five of the 14 authors, including the chair of the panel, had financial ties to statin manufacturers. In 2004, the "conflicts of interest were even worse."

"Eight of the nine experts who wrote the latest cholesterol guidelines also serve as paid speakers, consultants or researchers to the world's major drug companies -- Pfizer, Merck, Bristol-Myers Squibb, Novartis, Bayer, Abbott, AstraZeneca and GlaxoSmithKline. In most cases, the individual authors had multiple ties to at least four of these companies.

"One 'expert' had taken money from 10 of them," write Mr. Cassels and Mr. Moynihan. The links only became public when they were uncovered by journalists.

In Canada, the guidelines have expanded to include more and more people formerly considered "healthy." Earlier this year, the Canadian Medical Association Journal
reported that new Canadian guidelines have dramatically changed the threshold for "high" cholesterol so that an additional 500,000 Canadians should be taking statin medication -- at a cost of more than $250 million.

Almost all of the increase, according to the CMAJ, consisted of low-risk patients. The number of low-risk people for whom statins are recommended -- if lifestyle modification fails to achieve target lipid levels -- increased tenfold to 595,000 from 61,000. Yet, they reported that the relative benefit of statin therapy for many people in the low-risk group is "incredibly small."

Individuals who have heart disease may reduce the threat of heart attack by five or six per cent over 10 years by taking a statin every day. But there is no good evidence to show statins reduce the chance of premature death in low-risk groups.

Evidence also suggests high-risk individuals are being underprescribed while drugs are wildly overprescribed to low-risk individuals.

Mr. Cassels worries about the long-term consequences, especially because some of these drugs were linked recently to potentially fatal muscle-weakening disease. This summer, Health Canada warned that some of the millions of Canadians taking statins risk developing muscle-related problems that could lead to kidney failure and death.

In an interview, Mr. Cassels said doctors must stop overprescribing drugs to healthy people. He blames the cosiness between doctors and drug reps, who litter medical offices with free samples and misleading information on the benefits of drug therapy.

Mr. Cassels says some health advocacy groups are fighting to force the health-care system to again redefine the boundaries, this time reducing them. One U.S. group is campaigning for an independent review of official cholesterol guidelines.

Mr. Cassels acknowledges that many might shrug, asking what harm an extra pill a day can do. Look at the big picture, he urges. The $250 million it costs to put low-risk patients on statins could go to reducing waiting lists or buying more useful services from doctors.

Shelley Page's Second Opinion column on health-related issues runs weekly.

She can be reached at spage@thecitizen.canwest.com