Happiness & Public Policy

The NYT’s article Tuesday on psychiatrist David Healy shows a putatively scientific profession with an apparently strong motive to avoid addressing important questions. Healy was the first to argue that some anti-depressents may increase the risk of suicide in some patients. This seems like the sort of claim that a scientific-medical community would want to fairly investigate. But Healy has become a pariah:

“People have called it the Healy effect,” said Dr. Jane Garland, chief of the Mood and Anxiety Disorders Clinic at British Columbia Children’s Hospital in Vancouver, who shares some of Dr. Healy’s concerns about drug risks. “If you even raise the same issues he does, you’re classified as being with David Healy and that makes people very reluctant to talk. He has become very isolated.”

Why are people reluctant to talk? What are other psychiatrists afraid of? The Times doesn’t really draw it out, and leaves us to guess. Here’s my guess.

The problem appears to be that Healy, one of the world’s top experts on anti-depressants, has testified against companies like Eli Lilly and Pfizer. Companies forced to spend millions (billions?) navigating FDA’s insane drug approval maze, have perverse incentives to minimize the perception of their drug’s risk. Billions of dollars are at stake. So it’s easy to understand how pharma would see Healy as a “problem.” But why do others in the psychiatric profession consider this a topic too hot to touch? Simply because they fear that people who need anti-depressants will be scared away? Possibly. I think that this passage from the important Horwitz & Wakefield article gets to the core of it:

To obtain reimbursement for the treatment of such patients, the clinician must classify the individual within a DSM category of disorder, and depression is one of the more commonly used and easier ones to justify given the ubiquity of its symptoms. The result is a strange case of two “wrongs” seemingly making a “right”: The DSM provides flawed criteria that do not adequately distinguish disorder from nondisorder; the clinicians, knowingly or unknowingly, incorrectly classifies a normal individual as disordered (Why should the clinician question a diagnosis officially sanctioned by the DSM?); and the patient receives desired treatment for which the therapist is reimbursed.

Now, it should not be necessary to get a note from a medical guild member to be able to purchase anti-depressants. Even if you’re not really ill, but just sad, some Xanax just might be the pick up you need, and you should be able to get it. (It may actually interfere with normal coping mechanisms, so that’s the risk you take.) People want it. And doctors don’t see much wrong with people getting it if it could help them, whether or not they’re “sick.” So doctors write prescriptions for the stuff like its candy. Folks get what they want, and doctors get money from the insurance company. Everyone (except the insurance company and everyone who pays insurance premiums) wins! But if it comes to light that Prozac or whatever can make some patients suicidal, that throws a real kink in the cozy arrangement. It’s not just that some people, who may or may not need anti-depressants, will be scared off. Doctors, fearing liability if they prescribe to the wrong person, will be scared off from promiscuously offering prescriptions. But when that’s basically your bread and butter, the suicide risk is not a welcome development. And, really, the risk is surpassingly small. So why must Healy threatent to ruin the status quo for something so trivial.

Or maybe Healy’s just wrong on the evidence. I don’t know. But I suspect Healy is a pariah in larg is part due to the cluster%&!# of bad incentives created by the FDA, the medical guilds, the drug laws, and the liability laws.