3.3.1 A conflict of interest
One of the difficulties of the involvement of drug companies in the mental health field is that it produces a conflict of interest. To put it crudely, drug companies rely on a continuing supply of patients to keep them in business. This is not always congruent with people's best interests, as you will see below. Although mental health services are intended to help people experiencing mental distress, they also have other driving forces. The market economy model of provision has encouraged the expansion of various aspects of mental health care, but has fuelled, in particular, the development and promotion of drugs to such an extent that it is now a huge business. Between 1992 and 1997 government spending on mental health services rose from £2.6bn to £2.8bn (Bird, 1999), and current plans indicate further rises. The impact of the pharmaceutical industry is perhaps most pronounced in the USA, where there is a view that ‘psychiatry has been almost bought out by the drug companies’ (Mosher, 1999, p. 16).
Concern about this conflict of interest has a long history. In 1965, a journalist from the Washington Post wrote about the ‘therapeutic nightmare’ of psychiatric drugs being used to control ‘millions’ (Mintz, 1965). In 1974, the American Journal of Psychiatry raised concerns that ties between the American Psychiatric Association (APA) and pharmaceutical companies were going beyond the bounds of professionalism, compromising the organisation's principles, and in some instances involving members in conflicts of interest (Breggin, 1993). By the 1980s a small but visible lobby within psychiatry was opposing the influence of the pharmaceutical companies. The main concerns were that:
Drug companies influenced individual psychiatrists' prescribing decisions through heavy promotion at the conferences and in the academic journals they sponsored.
The dependence of university research departments on drug company funding might lead to bias in their results, particularly the results of studies evaluating the efficacy and safety of particular drugs.
(Source: Metzl, 2003, p. 140)
More recently, for example, there is a growing medicalisation of everyday life, with new conditions such as ADHD being ‘discovered’ and then treated with drugs. The use of Ritalin to treat children with this newly discovered ‘problem’ is widespread, with millions of children being given it daily. At the same time, autism diagnoses have increased 1,000 per cent over a decade, paving the way, some argue, for the introduction of a new drug to treat it (Boyle, 2003).
Whatever the cause, the trend of prescribing drugs opened the divide between the psychiatric professions and charities such as Mind that campaigned on behalf of people experiencing mental distress. The run-up to the Mental Health Act 1983 saw Mind and others arguing for stricter controls on the use of drugs for patients detained against their will. A decade later the pharmaceutical industry was rethinking its strategy for marketing to the NHS, following the creation of the internal market:
Glaxo Laboratories has an NHS Relations Unit which was set up in response to the major changes in the NHS structure […] Links are being established at managerial level in regional health authorities, district health authorities and family health services authorities.
Persuading professionals to prescribe a particular drug is vitally important to drug companies. For example, a single prescription for paroxetine (Seroxat) is £22, while diazepam (Valium) is 90p. Just how big is the market for antidepressants? Table 1 gives an indication of the market for three antidepressants: fluoxetine (Prozac), paroxetine (Seroxat) and venlafaxine (Efexor XL).
Table 1 The antidepressant market (England)
|Total number of items dispensed (000s)||Cost per item (£)|
As Table 1 illustrates, the growth in the market for this new generation of antidepressants has been dramatic, and marketing strategies are an ongoing focus for pharmaceutical companies. This growth is raising some concerns, as the following extract illustrates.
While health regulators are becoming increasingly anxious to control the use of Seroxat and other antidepressants, drug companies – equally anxious to gain as much income as possible from their medicinal cash cows – are trying to expand their uptake.
GlaxoSmithKline has made billions out of Seroxat and sees no reason why this should halt, it would appear. One of its internal marketing documents shows the company planned to double sales by targeting people who suffer from a widely recognised condition known as social phobias.
(Doward and McKie, 2004, p. 7)
So, it can be extremely lucrative for a company to produce and successfully market a drug which is widely prescribed. Just how did this situation come about? In the next section you look at the history of the use of drugs for people experiencing mental distress by tracking the introduction of successive waves of medication, from early antipsychotics to selective seratonin re-uptake inhibitors (SSRIs).