From Bill Lichtenstein
Senior Executive Producer, The Infinite Mind

In their May 6 Slate article, Jeanne Lenzer and Shannon Brownlee use The Infinite Mind's recent program "Prozac Nation: Revisited" to frame an argument that pharmaceutical companies are planting "stealth marketers" inside seemingly objective media outlets to manipulate public opinion. The article suggests that as public radio producers we have allowed our guests on our national weekly program to hide financial links with pharmaceutical companies for the purpose of promoting the use of dangerous prescription drugs.

Ironically, "Prozac Nation: Revisited" was intended to examine the way the media has handled links between violent behavior, suicide and antidepressants. Our interest in the story began with press reports about Steven Kazmierczak, whose shooting rampage at Northern Illinois University left six dead and 16 wounded. We wanted to know: Why did the major news media uniformly target Steven's withdrawal from an antidepressant as explanation for his violent act? Why did the media ignore any number of other factors, such as his gun collection, his work as a prison guard, or his troubled childhood? We were interested in exploring the reflexive public reaction that ends up making the medication the culprit, and so simplifies a disturbing violent act while stigmatizing the already vulnerable people who take or consider taking prescription medication for depression.

And at the core of the program, we asked the question we always ask, the question that has guided the past 10 years of The Infinite Mind: Where is the best science on this particular issue? In this case, does the science find links between antidepressant medications and out-of-control behavior?

To help us, we turned to recognized experts in the field. Framing the discussion, we began with Dr. Andrew Leuchter, director of UCLA's Laboratory of Behavior and Pharmacology, who himself has conducted much of the important research in this area.

Next, we spoke with Dr. Nada Stotland, current president of the American Psychiatric Association and an expert in medical ethics. Dr. Stotland, another distinguished research scientist and clinician, spoke about the gap between public perception and the research about violence, suicide and psycho pharmaceutical medications.

Finally, we talked to Peter Pitts, a former associate commissioner for the Food and Drug Administration who was involved in the FDA's 2004 "black box" labeling of antidepressants as carrying a risk of suicidal thoughts and behavior, and who was at the time the "go-to" guy for the FDA on that issue.

What we didn't know, because he didn't disclose it to us, was that Pitts is currently working for a public relations firm whose clients include major pharmaceutical companies. If we had known, and (full mea culpa here) we should have, we would have disclosed that connection. Pitts apparently didn't disclose it elsewhere, either - he's appeared on NPR's Talk of the Nation as well as PBS' News Hour with Jim Lehrer, without either of those programs mentioning the PR company ties.

In any case, to suggest that distinguished researchers such as Drs. Stotland and Leuchter are shills for the drug industry is bad journalism. Pharmaceutical companies fund the lion's share of research being conducted today. There are strict ethical codes and laws governing the use of such funds. Journalists covering this industry know that, and routinely disclose only those ties that are likely to raise serious questions about a researcher's neutrality. It would be patently ridiculous, for example, to presume that Dr. Stotland, speaking for all American psychiatrists as president of the APA, would somehow distort the truth because of some past connection to an industry speakers' bureau.

It is important to state that we stand by the program and its editorial content. There is, as our guests observed, no credible evidence that the use of antidepressants contributes to the sort of violence that erupted at NIU. There is, on the other hand, a study by the Centers for Disease Control and Prevention suggesting that more young people may be dying in part because of the chilling effect of the FDA "black box" warning. While some will take issue with these studies, we believe they are important, that they deepen the public dialog, and that they've gotten lost in superficial media coverage of a complex issue.

So finally, let's tackle the other question raised in the Slate article: Is it acceptable for a public radio program about the human mind to take grants from the pharmaceutical industry?

Back in 1994, I came face to face with that question. Preparing to produce a program about people living with schizophrenia, I met with Delano Lewis, who was at the time president of National Public Radio. I told Lewis that I had offers of unrestricted educational grants from several pharmaceutical companies who were interested in helping lift some of the stigma about this misunderstood and feared disease, but that I wasn't sure whether it would be proper to accept the grants.

The conversation that we had helped set the ground rules that have governed our underwriting ever since. Lewis began by observing that in many cases, especially on difficult and unpopular subjects, it would be hard to find support from organizations without some kind of substantial interest in the subject matter. The important thing, he said, was to assure listeners and stations that there was an absolute firewall between funding sources and editorial decision-making.

With this in mind, 14 years ago, we created a system with the following rules: We would take no more than 15 percent of our total budget from any one industry sector. We would not take substantial amounts from any one company. Corporate support would have to come in the form of unrestricted "no strings attached" educational grants. Corporate funding would be mixed with support from other sources (in the case of The Infinite Mind, that's been sources like the MacArthur Foundation, the National Institutes of Health and the National Science Foundation.) We would list underwriters on the air. Under no circumstance would producers ever have editorial discussions with any funder; and it's probably important to note that in the case of the pharmaceutical industry, such conversations would be a violation of federal law as well as a violation of our own ethics as journalists. And, we would require employees to sign a code of conduct that requires disclosure of any potential conflict of interest and makes failure to disclose a fireable offense.

By the way, our 1994 program on schizophrenia, with substantial and disclosed support from the pharmaceutical industry, won a Peabody Award and was credited with changing the way Americans look at people with serious mental illness. Over the past 18 years, following these rules, our programming on the human mind has been honored with more than 60 awards for journalistic excellence and offering insight into issues that society would often prefer to ignore.

In the interest of full disclosure, I also should note for the record that Lenzer, who co-authored the Slate article, called me a few days after the "Prozac Nation: Revisited" program aired to pitch a program that she wanted us to do for The Infinite Mind, called "Journalists on Prozac," which would feature her and her writing partner Shannon Brownlee. Checking into Lenzer's credentials, I found a troubling article in The New York Times taking her to task for a British Medical Journal article that suggested that Eli Lilly and Company, which makes Prozac, had concealed documents about the link between anti-depressants, suicide and violence. The BMJ subsequently retracted the article, with full apologies, and the whole matter was widely covered in the news media.

After we told Jeanne Lenzer that we would not be proceeding with a program featuring her, she and Brownlee wrote the article for Slate.

The reason the media responded to the Prozac withdrawal or "discontinuation syndrome" of the NIU shooter rather than his troubled childhood or gun collection is because so many people in the media have been hurt by the SSRI antidepressants that they see all too clearly that the medicine was the cause.

Antidepressants have been known to cause mania & psychosis since their introduction in the late 1950's. Why the scientists can't figure out what is causing most of the school shootings is really weird. On www.SSRIstories.com there is a list with full media article available of 43 school shootings/incidents where the perpetrator was on antidepressants or in withdrawal from them.

Also, there was only a decrease in suicides among youth when there was finally a decrease among prescriptions for antidepressants which began in 2005. The Black Box warning was not placed on SSRIs until Sept 13. 2004. Do your homework, please. It is a matter of life and death.

To Rosie C.--

That 43 school shootings involves perpetrators who either were taking or recently had stopped taking SSRIs doesn't prove anything. First, you don't cite the number of shootings where the perpetrator was not using SSRIs, so one has no idea whether 43 accounts for the overwhelming majority of school shootings or not (though one hopes that there aren't many more than that). Assuming that it does, in fact, account for most cases, it still doesn't prove any causation: it's just as likely to interpret that statistic to mean that those perpetrators had some form of mental illness and would have committed those crimes regardless. It sounds like the logic of a true believer to me: you're convinced of the evils of all antidepressants (to lump in modern SSRIs with those that came out in the 1950s was a particularly nice touch) and no amount of careful presentation of evidence is going to convince you otherwise.

Although I don't have a dog in the fight over the harmful effects of SSRIs (but I suspect that the link between SSRIs and such violent acts is overblown), I do think that "The Infinite Mind" clearly erred in not opening the piece by disclosing all ties that exist between the program and the guests, on the one hand, and any pharmaceutical company making one of the drugs highlighted in the article. As a physician, I continually despair of the incestuous relationship that exists between high-ranking academic physicians and Big Pharma, and that the relationship is more or less taken for granted by most in the profession. Indeed, Mr. Lichtenstein, in his letter of reply to Lenzer and Brownlee, states that

"There are strict ethical codes and laws governing the use of such funds. Journalists covering this industry know that, and routinely disclose only those ties that are likely to raise serious questions about a researcher's neutrality. It would be patently ridiculous, for example, to presume that Dr. Stotland, speaking for all American psychiatrists as president of the APA, would somehow distort the truth because of some past connection to an industry speakers' bureau."

I, for one, don't think it's so ridiculous that a prestigious doctor's connections to industry could--indeed, should--call into question any pronoucement said person makes about drugs. But perhaps Mr. Lichtenstein, in his zeal for public radio, has managed not to view commercials featuring Dr. Jarvik extolling the praises of Crestor. At any rate, when he says that "journalists...routinely disclose only those ties that are likely to raise serious questions about a researchers neutrality," he seems to be implying that this is a rare or isolated event and not related to any of his guests on this episode, or for that matter any episodes of his show. That, too, seems a stretch: if I'm reading right Mr./Dr. Pitts had absolutely no business being on the show identified as anything other than an industry spokesman; Dr. Stotland has every reason (or at least tens of thousands of them, I would assume) to look favorably upon SSRIs given her speaker's fees and therefore has little or no credibility whatever her academic qualifications and status as APA President; only Dr. Leuchter--who is noted to receive research money, as opposed to speaking fees--seems like a reasonable choice as a relatively neutral guest, and even in his case there should have been full disclosure about the industry source of his research grants.

I do think that Brownlee and Lenzer miss a couple of subtleties that would be useful to laypeople. For one, Mr. Lichtenstein is right when he notes that industry is responsible for funding a large amount of pharmaceutical research and that, by taking that money, a researcher isn't necessarily compromised in their objectivity. That said, a huge number of those researchers also take speaking fees from the same companies, which to my mind is obviously unethical. And the editorial policies related to the grant money that The Infinite Mind receives from industry seems to have been well thought-out. I doubt the same can be said of the commercial TV news "Health Focus" segments, which are not only dismal but reach a much larger audience than those on NPR/PRI.

On the whole, though, I think Infinite Mind really did fail its listeners, and Mr. Lichtenstein's defensiveness in his reply to Slate does not indicate that he's understood the lesson here.

Billy Rubin,

Forget so-called 'logic'. Use common sense. If you read one of the older Physicians Desk References, there is a warning on one of th earlier antidepressants, Elavil. It says that this drug can exacerbate the symptoms of manic depression [bipolar disorder], schizophrenia and paranoia. Now I am a believer in "the Shadow Syndrome" as exemplified by the book of that name by John Ratey M.D.

That book has the premise that everybody has a "touch" of mental illness but that the majority of people never have it interfere with their daily lives. For instance, paranoia is part of human nature but it manages to stay undercover most of the time although it occasionally breaks loose as, for instance, in the Holacaust of World War II.

Now, physicians were hesitant to give adolescents Elavil because of side effects but, when Prozac ws introduced, it was introduced as being free of side effects so doctors began giving teen-agers the new antidepressants. Yes, not all of the school shooters were on antidepressants [in so far as we know] and a few of the school shootings that did not involve antidepressants might have been 'copy cat' but, to give millions of people a drug that can cause mania, psychosis, abnormal thinking, hostlity, etc. [and these are all listed in the PDR as adverse reactions to the SSRIs] is a 'crime against humanity'.

The 2005 UK Parliament review on "The Influence of Pharmaceutical Industry:

<link>

5.Problems with Seroxat and other SSRIs
Prozac and Seroxat are the best-known examples of SSRI and related antidepressants, but others are widely used.The introduction of SSRIs led to a threefold increase in antidepressant prescriptions between 1990 and 2000.Prescriptions for antidepressants now match those of the benzodiazepine tranquillisers at their peak, 25 years ago.
Almost from the outset,there was concern about two main problems with SSRIs.First, there was suspicion (initially centred on Prozac)that these drugs could induce suicidal and violent behaviour – infrequently, but independently of the suicidal thoughts that are linked to depression itself.There was also concern (centred on Seroxat)about a risk of dependence;some users found it impossible to stop taking SSRIs because of severe withdrawal symptoms. The MCA/CSM formally reviewed these problems on several occasions.The suicidality problem was first investigated in 1990/1;withdrawal reactions were investigated in 1993,
1996 and 1998.In 2002,the MCA organised a further intensive review of both problems. This review was abandoned in April 2003, following criticism about conflicts of interest involving key figures on the review team. p. 87

It's undeniable that suicidal ideation and violent behaviour under SSRIs has nothing to do with the depression.

I would like to remind you that during Cymbalta's test trial phase 5 health people committed suicide on Eli-Lilly's facilities.

One of them is Tracy Johnson. A 19 years old health girl hanged herself on Eli-Lilly's facilities during the trials.

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I've spent 2 years tapering Effexor. The reasons why I was prescribed this SSRI is a long story and I'll spare you the details.

I know what "Chemical Suicidal Ideation" is.

I have never been depressed and only had this hideous feeling during the period I was tapering the drug.

I also had impulses to self-harm. Never in my entire life I had such an impulse.

I hope people who are on SSRIs or considering taking it search a lot for it's really very dangerous and a questions of life an death.

Dear Mr Lichtenstein,

I posted this earlier in another post and sent an email to your show's address. Maybe you received it. In all this discussion about conflicts of interest I think everyone is glosssing over the innaccuracies of the show. Below are some comments from the guests and hosts that are at odds with the scientific literature.

Andrew Leuchter: “In those studies where this increase[d] thoughts about suicide and agitation were noted, actually, there were no suicides - that people thought about it but they didn’t act on it.”

This is a problematic statement. For instance in 1991 Glaxo submitted an analysis and reported that there were five suicides in the drug group. People might argue about the statistical significance compared to the placebo group but at least according to the FDA and Glaxo he has misspoken. What he most likely meant to say was that there were no reported suicides in the studies looking at the use of antidepressants in children. However even this is problematic as the case of Traci Johnson shows.

Goodwin: “There is no credible scientific evidence linking antidepressants to suicide or violence.”

This is a rather flippant statement about a large body of data, and again at odds with the FDA, as presumably the FDA believes that their decision to place a box warning on the SSRIs was based on an analysis of the scientific evidence. Goodwin not might agree with the data, but according to Healy (Lines of Evidence, 2003) there were more suicides and more thoughts about suicide in the trials for every single antidepressant studied. In the Zoloft group there were two suicides and in the Paxil group there were five, and the list goes on.

I think someone from your show needs to comment on these factual errors. If you need supporting documents I would be happy to send them to you.

Iit is unclear to me how you decided to have a show made up of experts who disagree with the FDA and you never considered having someone from the other side. How did this happen?

It is also odd that in your letter about Jeanne Lenzer and the BMJ having to retract their report that Lilly hid documents you provide a link to an article that shows Lilly knew about problems with Prozac. (The retraction was not about whether or not Lilly had internal documents suggesting that there was a problem with Prozac but whether or not they made the documents available to lawyers in a specific case. They did not make the documents available to the genral public)According to the very article which you cite,

"The London-based BMJ, formerly called the British Medical Journal, did not retract its contention that the documents show the antidepressant is linked to increased risk of suicide or violence. All we have retracted is the statement that these documents went missing," wrote acting editor Kamram Abbasi, in an e-mail to CNN. " -Jon Leo

Dr. Leo:

I had read your comments in February, 2005 to the BMJ retraction and was just going to post on them elsewhere.

"Why did Eli Lilly not share this data with the general medical community?"

Those words in themselves are a pretty damning statement and worthy of a response by Eli Lilly. I assume there was a response?

The courts take a dim view of crimes committed while mentally ill or in a diminished or no capacity state of mind. One can be either innocent, guilty, or guily but mentally ill. The last verdict being the same as guilty in which the case the court sentences the person in a similar manner as guilty. That Prozac may increase the likelihood of violence in some patients is troublesome and difficult to make a case for in the courts.

Wolfen,

I have reported you for "abuse". I think it is a sad day in this country when a person cannot have a decent discussion on the dangers of SSRI antidepressants without being called a Sceintologist.

I not only deeply resent it but I feel that the drug manufacturers are using the Scientology angle to their own benefit. Pharma is saying "We can have NO discussion about the "dark side" of Prozac/SSRIs because it is all being done by Scientologists."

Not only is this not true but it is disgusting and I would appreciate an apology. I am a Christian, a Catholic, and I do not like being called something that I am not.

Rosie:

The abuse would have to be more flagrant than what wolfen perceiveably has committed in order for Slate to take action. Your best bet is to ignore your antagonists and do not pay them credence with an answer.

I have been here a long time and short of calling one of the editors a Nazis once, I have not seen Slate take an extreme action. I was almost banned for calling a checkmarked poster an idiot for saying Canadian Oil was to expensive for the US to use (Canada is the US's #1 supplier). Just a suggestion . . .

Well, I am sick and tired of being called something I am not - which is I am not a Scientologist. But thanks for the tip.

I guess people don't realize that 4 million people have been hospitalized since 1988 [the first year Prozac was on the market] due to an SSRI antidepressant-induced mania and/or psychosis.

This statistic comes from a Yale University study. It was published in the Journal of Coinical Psychiatry 2001: 62: 30-33 and was titled: "Antidepressant-Associated Mania and Psychosis Resulting in Psuchiatric Admission" by Adrian Preda, M.D. and Malcolm B. Bowers, Jr,. M.D.

The most terrible part of this great national tragedy is that these 4 [four] million people were the lucky ones. Their physicians recognized what was happening to them on their SSRI antidepressant and hospitalized them. Not all were recognized. That is why www.SSRIstories.com/index.php has over 2,300 tragic cases now, including Columbine. The full media article is available on SSRI Stories Website so a person can view all the details.

Why NPR chose to endorse SSRI antidepressants is only a small part of the picture. The bigger picture is that the drug companies "own" the AMA, the newspapers [because their advertising is all that is keeping these newspapers in business] and the television stations [same scenario here as the newspapers]. Even the FDA is dominated by Pharma.

Sorry, but if you think that was "abuse," then you ought to remove The Fray from your Favorites list immediately.

I'm not a big fan of BigPharma, either. Especially in their over use of medication on wrongly diagnosed kids with alleged ADHD. But your rather extreme antagonism toward the psychiatric and pharma community, and then mention of "human rights" in the same phrasing, set off all the $cientology red flags.

Sorry if I offended you with the $cientology thing. But my question still stands: What do you suggest as the alternative?

Dr. Leo:

There is not a lot I can add to the story beyond what has been reported in the posting on NPR [ http://www.npr.org/ombudsman/ ] and the eloquent piece of reporting at STATS.org (click here): <link>

If you want to forward relevant research regarding scientific links between antidepressants and depression, I would be glad to review it.

With regard to the Lilly story, I would defer to the STATS.org article, which found that Lanzer's questionable reporting on that story, put "on balance, more lives at stake."

-BL

Wolfen:

Its ok, just clued her into the lay of the land around these parts.