Working as a psychiatrist in different countries, systems and settings as I did during the last 25 years has taught me that nothing is ever written in stone. What is considered safe and effective in one place may be looked at as harmful or useless in another. Psychiatry is definitively not an exact science and working with human beings' sufferings often needs more creativity than rigid guidelines. When working as a community psychiatrist we learn very rapidly the limits of what we were taught in academic forums and research literature. Reading David Healy's book comforted me in something that patients (our co-partners in the difficult business of healing bruised souls) had convinced me of a long time ago: how much they know and how carefully we need to listen to them ...
David Healy is a serious man. As a caring clinician and internationally recognized expert in pharmacology, epidemiology and the history of psychiatry, this Irish professor may be reminiscent of both Sherlock Holmes and Atticus Finch.
His latest book, Pharmageddon, is a riveting detective story, a meticulous account of the troubling evolution of the practice of medicine and a compelling plea for a better protection of those that medicine is supposed to serve. It is a must-read for all of us. Beware though, that, as a physician or as someone who will sooner or later be a client of the healthcare system, you may be in for a painful ride. It takes only a few pages to realize that, if you are a health care provider, you may already have become, willingly of not, an accomplice of a system that has slowly but surely drifted from the shores of a "First do no harm" philosophy to shores covered by a growing number of victims of poorly or overly prescribed medications. Adverse drug events are currently the fourth leading cause of death in the US and Europe , and possibly the leading cause of death within the mental health domain.
David Healy is a courageous man. Twenty years ago, when psychiatrists, like everybody else, wanted so much to believe in the quasi miraculous and purely benevolent powers of new and heavily marketed drugs, he was among the first to take the risky and unpopular position of pointing out the emperor new clothes. He cautioned us that the same pills that may relieve severe depression and save lives may also, occasionally, be the cause of suicidal thoughts and sometimes of suicide itself. By doing this, he saved lives, while compromising his own academic career in a world where academia and research have become increasingly and, in some places, totally dependent upon the financial support of the for-profit pharmaceutical industry.
In Pharmaggedon, the author expands his observations from psychiatry to the entire field of medicine. With carefully documented evidence, he brings us on a journey to observe the worrisome directions taken by medicine, which went from a cautious use of potentially poisonous substances and a denunciation of charlatanism to a profession hijacked by the greed of the Pharmaco-Industrial Complex and the doctors who benefit from it. One of the most stunning observations is how "evidence-based medicine," which was developed initially to protect society from quackery, has become the very tool used to turn data inside out in order to "advertise" medications as efficacious or totally safe while, too often, they are neither. Again and again, Healy demonstrates how the globalization and mercantilisation of clinical trials, together with the limited access to raw data from published and unpublished studies, and the ever expanding use of ghostwriting, have often turned evidence-based research into no more than a gimmick to increase sales.
Medical ghostwriting is a practice where pharmaceutical or device companies hire medical education, marketing, or communications companies to draft articles that are presented to prominent physicians and scientists to sign on as "authors." The idea, then, is that this will increase the likelihood that the article will be published in important medical journals. The articles may be review articles, editorials, or primary research papers, and they are typically presented to physicians and scientists affiliated with academic institutions. The physicians and scientists agree to sign on even if they may not be intimately familiar with the underlying data or relevant research or provided limited input on the article. Healy estimate than over half of the current medical literature has been "ghostwritten."
This drift from science to evidence-biased medicine, and the latter's role in the development of rigid and sometimes inappropriate guidelines, is very disturbing and makes for a very bleak future. Trust, the cornerstone of the relationship between a patient/consumer and his or her physician, seems doomed. Similarly, the trust that a physician needs to have in academia and Pharma in order to subject those in their care to potentially dangerous substances is also highly compromised. Some may regret that, by insisting mostly on the dangers of medications, David Healy does not put enough emphasis on their positive and life saving properties and the true improvement that have been made in reducing side effects. Maybe Healy considered that enough literature has been (ghost) written already on these aspects of pharmacology and that his erudition would be of better use in exposing truths that the majority of us were not aware of.
But Healy is not just a spoil-sport. As a good old fashioned physician, he proposes remedies to change a self-destructive medical dynamic. One of the most feasible and important changes that he recommends is the provision of full and free access to raw research data. It is shocking that these data are not already in the public domain since the interpretation of them affects not only our health but a good part of our economy. Another point made by Healy is to challenge a "prescription-only" system because a "prescription-only arrangement means that doctors have to give us disease if they want to give us pills" (or I would add, if they want to be paid).
I may need a little more convincing from the author as to what would safely replace this system. I would hope that this problem could be addressed with the regular updating of physicians' pharmacological knowledge - one where we would be considered smart and mature enough by academia and Pharma - to be informed of the risks of a molecule as well as their vaunted benefits. Other useful changes could be made at the level of billing practices, for instance in the design of a system that does not penalize the doctor financially for not prescribing anything.
David Healy has put theory into practice by creating RxISK.org, a free website (not sponsored by Pharma or advertising) for patients and their doctors to research and report drug side effects.
There is certainly a long road between appealing ideas and their execution in a world dominated by people who may all have some short-term interest in the status quo.
Let's hope, however, that, just as Atticus Finch's words helped to transform society for the better, David's Healy's Pharmageddon will give us the tools, courage and strength to rethink and transform the way medicine is designed and delivered.
Finally, if there is only one thought you want remember from this book, it should be this almost prophetic counsel by Philippe Pinel, from two hundred years ago: "It is an art of no little importance to administer (medication) properly, but it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them."
Amen.
Bernadette Grosjean.M.D.
Associate Professor of Psychiatry
David Geffen School of Medicine at UCLA
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Reviewed in the United Kingdom on December 15, 2014
