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Monday, November 30, 2009

Big Pharma Drama in Iceland

Icelandic academic and Neuroskeptic reader Steindór J. Erlingsson reports that thanks to his efforts, pharmaceutical company GlaxoSmithKlein (GSK) has stopped distributing a booklet promoting the monoamine hypothesis of depression to pharmacies and doctors offices in Iceland.

His report is here, and it has links to more details on the story, although these are in Icelandic, a language I'm unfortunately not familiar with. In a nutshell, Erlingsson says he spoke to the Icelandic Medical Director of Health who, after some back-and-forth and consultations with psychiatrists, contacted GSK.

On September 29th GSK announced that they
have received information that its information booklet on depression needs to be improved. The company views favorably well argued suggestions and as a result it is going to review the booklet.
They went on to say that the booklet, which had been around since 1999, should no longer be distributed. According to Erlingsson, the booklet made three claims:
1. An imbalance in the neurotransmitter serotonin causes depression. 2. SSRIs treat depression by correcting the serotonin imbalance. 3. Psychological treatment is ineffective in treating the serotonin imbalance.
Coincidentally, GSK are the manufacturers of paroxetine (Paxil, Seroxat), one of the best-selling SSRIs. Iceland, like most countries (except the US and New Zealand), bans direct-to-consumer advertising for drugs, but this kind of thing is not covered by such laws.

Personally I believe that serotonin probably is involved in some cases of depression. My views on the serotonin hypothesis of depression are therefore more favorable than those of many critics for whom the whole idea is a myth. But even so, I'm happy that to hear that this booklet has been withdrawn. Drug companies have no business promoting the serotonin hypothesis to the public.

First off, because it's controversial science. There's no "smoking gun" proof linking serotonin to depression. There's a lot of circumstantial evidence, but we don't really know how antidepressants work, or indeed how well they work, at all. For once, we should be "Teaching the Controversy". Most of the time when people say that, they're wrong, because they're talking about science which is rock solid, like the theory of evolution. The monoamine theory, however actually is controversial, which is why there are articles in major scientific journals criticizing it and others defending it.

Second, because the monoamine theory is certainly not true in any simple sense. Low serotonin levels cannot be the sole cause of depression because you can temporarily deplete someone's serotonin with a technique called tryptophan depletion and for most people, this does nothing at all to their mood. On the other hand about 50% of people who have suffered from depression in the past do get depressed again after tryptophan depletion, which is why I think there is some truth in the serotonin theory, but this shows that it's not a straightforward picture.

Third, the idea that only drugs can correct the "chemical imbalance" and psychotherapy can't is simply wrong. I don't know what the wording of GSK's booklet was, but from Erlingsson's summary, it sounds like it was giving people medical advice - you won't benefit from therapy - via leaflet, which is very irresponsible. Only a clinician with personal experience of an individual patient can say what treatment is best for them. Some people benefit from therapy, others do well on medication, and some people get better with no treatment at all. It sounds like GSK is behaving just as Oliver James did when he used the Guardian to recommend Freudian psychoanalysis over drugs and other kinds of therapy for postnatal depression. They're both wrong.

On the other hand, information leaflets telling people about depression and encouraging sufferers to seek professional help sound like a great idea to me, because many people with depression go undiagnosed and untreated and that's a real tragedy. But drug companies are unlikely to be the best people to provide such information.

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