Author: Gordon McCarter
Position: Assistant Professor, Biological Sciences
Institution: College of Pharmacy, Touro University - California
E-mail: gmccarter@touro.edu
Submitted Date: November 23, 2005
Published Date: November 25, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Lacasse and Leo make an important contribution in the debate over prescription drug advertising. Their demonstration of the ubiquity of the scientifically unsupported claim that SSRIs "correct a chemical imbalance" points out the need for better regulation of direct-to-consumer (DTC) advertising by the FDA. This question then leads to the larger issue of how the public gets unbiased information on which to base rational choices for the different treatment options that may be available for particular diseases.

First, it should be emphasized that the "monoamine hypothesis" of depression has not been proven wrong; it is simply very incomplete. Inhibiting the serotonin and/or norepinephrine transporter(s) clearly relieves the symptoms of major depression for many patients, and the safety profiles of the current SSRIs and SNRIs are quite favorable. Nevertheless, the exclusively pharmaceutical and commercial approach to the treatment of depression that the typical consumer is exposed to in the media does a grave disservice to those who might benefit from the many other treatment options available.

The realization that depression is a true physical disease has allowed millions of sufferers to seek treatment and has removed much of the guilt and shame (or proud forbearance) that sometimes resulted from a predominately psychodynamic conception of the causes of depression. Earlier, when very little else was known about the etiology of the disease, it might have been helpful to describe the action of the available drugs to patients as "correcting an imbalance" in brain neurotransmitters. Now, with so much more that is known or strongly suggested about the biology of depression, it is irresponsible for anyone in the medical community to describe it as simply a "chemical imbalance." The implications of the heritability of a predisposition, the role of early life trauma, the involvement of stress hormones, the observations of neuronal atrophy, and the possible link to hippocampal neurogenesis all have implications for treatment that lead in many directions other than simply a pharmaceutical approach. These include nutrition, exercise, and certain forms of psychotherapy, especially cognitive-behavioral therapy.

But how would a depressed person know about all these treatment options? If he's lucky he might be induced to visit his doctor, perhaps by DTC advertising, who would then describe current thinking about depression and could try to determine the best treatment for the patient??s situation. But doctors are extremely overworked these days and they too are the targets of advertising by pharmaceutical companies. Indeed, "medical education" is a huge industry through which these firms, at one remove, attempt to influence medical practice by the sponsoring of meetings, symposia, and journal supplements and by the well-remunerated enlistment of academic "opinion leaders" to present and author these usually ghost-written pieces. The result is a knowledge environment that is overwhelmingly dominated by the perspective of commercial interests.

The answer, of course, is education, both of physicians and patients. A nice way to achieve this, and to refrain from infringing on anyone's free speech, would be to require that any expenditure on advertising by pharmaceutical or medical device manufacturers be matched by contributions to an unbiased education fund administered by the FDA, the NIH, or both. This fund could be used to produce public service announcements of clear and balanced information regarding the particular therapeutic area the company's product addresses. However it is funded, the federal government is the only entity with the resources and reach to be an effective counterweight to the commercial medical perspective. There are few roles that may be as important for a national government than the protection of its citizens' health through effective regulation of the presentation of medical information.