High Anxiety

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High Anxiety
By Anne McIlroy
The Globe and Mail
9-20-3

Nervousness, Panic And Shyness Are Now Part Of The Most-Diagnosed Group Of Mental Illnesses - And Drug Companies Just Happen To Have An Array Of Products To Treat Them. Is Marketing The Tail Wagging This Dog?

The questions on the Internet quiz were making me anxious. Am I bothered by blushing in front of people? Well, somewhat. Do parties and social events scare me? Somewhat. I tend to like small dinner parties and I get nervous walking into big bashes. Does fear of embarrassment cause me to avoid doing things or speaking in front of people? Somewhat. I'm a bit shy, and don't like speaking in large meetings.

I click a button to send in my answers, most of them "somewhats," and a few seconds later the results arrive from a drug company Web site: 34 out of a possible 68.

"Your score suggests that you may be experiencing the symptoms of a social-anxiety disorder. We encourage you to make an appointment with a qualified health-care professional to discuss your symptoms," says the response from the site for Paxil, a drug that has generated rocketing sales as a treatment for anxiety disorders.

Twenty years ago, social anxiety was a new and rare mental illness, characterized by debilitating shyness and fear of being humiliated in public. Today, it is being billed as the third-largest mental-health problem in the world, and one of half-a-dozen anxiety disorders that are probably the most diagnosed mental illnesses on the planet.

The anxiety disorders include panic disorder, marked by frequent panic attacks that leave people feeling like they are dying of a heart attack or suffocating to death. There is also generalized anxiety disorder, characterized by immobilizing worry.

If depression was the disease of the moment in the 1990s, anxiety is the new depression. According to some estimates, social-anxiety disorder affects 8 per cent of the population of many countries, including Canada. A recent Statistics Canada study found that 750,000 Canadians reported symptoms consistent with the diagnosis.

Many mental-health professionals describe anxiety disorders as a hidden epidemic that has limited the lives of thousands of people who didn't realize anything could be done to help them, and argue it is still underdiagnosed. Others are worried about the role marketing has played in the rise of social anxiety and the other anxiety disorders.

Ad campaigns have focused on symptoms that, taken in isolation, are relatively common: Feeling shy, tense, worried? Having difficulty sleeping? Scared to speak in front of others? The solution, they suggest is a pill -- most likely a selective serotonin reuptake inhibitor, or SSRI.

These blockbuster antidepressants -- Paxil, Prozac, Zoloft, Celexa and others -- are generating a new wave of profits as anti-anxiety drugs. In 2002, the SSRIs were the second-most prescribed drug in the United States, behind the painkiller codeine. For the past three years, the number of prescriptions has grown in Canada by up to 20 per cent a year, according to IMF Canada, a health-information company.

"These drugs aren't meant to be treating normal emotional responses to things that go wrong in someone's life, but that distinction has been blurred," says Barbara Mintzes, a University of British Columbia health-policy researcher.

In one case, a graduate student at a B.C. university is feeling anxious about her master's thesis, and visits the campus clinic. The doctor puts her on Prozac; she loses weight and sex drive, but is still anxious, so she stops taking the drug. A few years later, she is a month away from defending her PhD dissertation and is again overcome with anxiety. She has constant butterflies, nausea, outbreaks of sweat and trouble sleeping. She visits the clinic again to get counselling to help her manage her stress, but instead is give a free sample of Paxil.

"I only had a month to go, so I decided it wasn't worth it," says the women, who asked not to be identified.

Another woman, a 33-year-old project manager in Los Angeles, seeks help for chronic insomnia. She is given Paxil. It doesn't help, so after six weeks she slowly tapers her dose. That's when she says her problems really start. She has panic attacks, and feels dizzy and nauseous. Her doctor tells her to get back on the drug, and that she will probably have to take it for the rest of her life. She refuses, and her symptoms mostly clear up over two months.

"I still have trouble remembering things, and connecting thoughts to speech," she says.

Dr. Mintzes worries that the aggressive ad campaigns may promote drug use among relatively healthy people, and may "medicalize" normal human conditions. She points to an ad that GlaxoSmithKline, the makers of Paxil, ran in the New York Times Magazine after the Sept. 11, 2001, terrorist attacks: "Millions suffer from chronic anxiety. Millions could be helped by Paxil," it read.

"At what point," Dr. Mintzes asks, "does an understandable response to distressing life events become an indication for drug treatment -- and a market opportunity?"

She has taken the same Paxil site "self-test" for anxiety that I did, as well as other diagnostic tests on the Web. Her results? "I need medication. No matter what the problem is, I have it."

We agree that neither of us has an anxiety disorder, or any need to talk to our doctors about our "symptoms." I find this comforting.

Anxiety disorders are serious mental illnesses, and thousands of Canadians do suffer terribly from them. No one is suggesting they aren't truly sick, or that drugs such as Paxil or Zoloft don't help many get better.

Jonathan Baker, for instance, is a 32-year-old Ottawa man who used to love to party. He hung on to his student lifestyle after he finished his education and got a job writing advertising copy at an Ottawa radio station. He was still living at home with his parents one night in January, 1996, when he felt his heart pounding against his ribs, and thought that he might be having a heart attack. At the hospital, the doctor who hooked him up to a monitor told Mr. Baker there was nothing wrong with his heart.

But his personality was changing. He didn't want to go out, preferring to stay home and rent movies. When he did go to, say, a hockey game, he scouted out the exits. Soon, he was spending more time at social events planning how he would leave than enjoying himself. One day, halfway to Toronto, he was overwhelmed by an overpowering urge to return home. Traffic jams were hell. He always needed an escape route in case his heart started its wild thumping again or he had trouble breathing.

His New Year's resolution that year was to stop what he described then only as "these feelings." But they got the upper hand during a visit to Vermont with his girlfriend in August, 1997. He became hysterical, convinced once again he was having a heart attack. She took him the hospital, where the doctor who examined him told him that he needed psychiatric help.

He had panic disorder, characterized by the frequent and debilitating panic attacks. He was getting four or five a week. Shortly after he started treatment, he lost it on a plane: "I'm crying. I'm hysterical. I'm at the back of the plane telling the flight attendant that I've got to get off the plane."

Mr. Baker was no victim of marketing. "At first, I thought I was the only one in the world that had stuff like this happening to them. Now it's fashionable. It's trendy," he says, half-joking. "I can see how people who see all those ads might dismiss it, say it isn't real. But it is."

Others, however, may be getting medicated for feelings that are part of the normal range of human experience. A Toronto psychiatrist says he has had more than one parent demanding a drug for their anxious children, and in fact SSRI use among minors is on the rise.

"I see people taking these like candy, but they can have serious side effects," says Janet Currie, a member of Pharmawatch, a national organization concerned with drug safety. Potential reactions may include malaise, hypertension, intense itching, weight loss, weight gain, chills, dizziness, blurred vision, abnormal ejaculation and impotence. Many patients report difficulty getting off some SSRIs. They may even trigger suicide attempts or violent behaviour in some patients shortly after they begin to take the medication.

This worst-case scenario is what Mark Miller believes happened to his son, Matt, who in 1997 was prescribed Zoloft by a psychiatrist because he was anxious about fitting in at a new school and angry with his family. Six days later, he hung himself. Mr. Miller sued Pfizer Inc. and lost. But his lawyer, Andy Vickery, argued in an appeal this week in a Denver court that the boy "was anxious, but that drug was not what he needed."

David Healy, a respected researcher and psychiatrist at the University of Wales, believes that SSRIs are being overprescribed. "They are being used appropriately to treat a group of people, but they are also being used far too easily," he says.

Dr. Healy has been an outspoken critic of the close relationship between drug companies and researchers, and an expert witness on behalf of patients suing SSRI manufacturers in several U.S. lawsuits. In 2000, he was offered at job at the Centre for Addiction and Mental Health, only to see it revoked after he gave a speech on SSRIs and suicide. The centre, a University of Toronto teaching hospital, denied that its decision had anything to do with the fact that Eli Lilly, the maker of Prozac, was a major donor.

As the author of several books on the history of psychopharmacology, Dr. Healy has become familiar with how pharmaceutical companies market their drugs -- by marketing diseases such as anxiety. Typically, companies fund patient groups to promote awareness of a condition, and get big names in psychiatry to attend all-expenses-paid conferences. Many psychiatrists aren't aware of the influence the drug industry has, for example on research published in scientific journals. He is disturbed by practices such as "ghost writing," in which prominent researchers attach their names to scientific papers that have already been written by people hired by drug companies.

According to Dr. Healy, "The situation you have with Zoloft and Prozac is the same as you had with Valium in the 1970s."

Anxiety was known as nervousness until the 1950s, when doctors switched to the newer term and began prescribing Librium, Valium and other benzodiazepines (which are still in use and indeed, some would argue, still overprescribed).

The "benzos" were starting to get a reputation for being addictive in the late 1960s, says Edward Shorter, a professor in the history of medicine at the University of Toronto. As well, the old drugs' patents were expiring, and drug companies were working on a new class of drugs.

SSRIs were first targeted at depression as a marketing decision, Dr. Shorter says, because anxiety had a tainted image. "In the 1990s, depression became the disease of fashion, and everyone that previously would have been called nervous or anxious now became depressed. What is fascinating, in the last few years, is to watch the SSRIs being repositioned for anxiety."

But the marketing of anxiety really began before the repositioning of the SSRIs. In 1980, the American Psychiatric Association revised the meaning of anxiety, as part of a regular ritual in which a small committee of experts updates the diagnostic manual psychiatrists and scientists use in defining mental illness. This time around, the experts broke anxiety into a number of discrete disorders including panic, social anxiety and generalized anxiety.

What happened next was a textbook case -- in fact, one of the original examples -- of how to market a disorder to build a niche for a drug, Dr. Healy says.

The Upjohn pharmaceutical company sought to market what was then a new benzodiazepine called Xanax for panic disorder. Upjohn sponsored scientific meetings on panic disorder, often in exotic locations. Some of the most distinguished figures in psychiatry attended. The company supported research on Xanax that showed it worked better than a placebo, which is the critical measure the U.S. Food and Drug Administration looks at when approving an existing drug for treatment of a new condition. (In Canada, once a drug has been approved for one illness, doctors can prescribe it for any disorder.)

At times, the Upjohn marketing machine seemed to be selling the disease to the public as much as the potential cure, Dr. Healy says. "When finally launched, adverts for the new drug featured panic more prominently than Xanax."

Media attention followed. The BBC and NBC did programs on panic disorder and The New York Times and Washington Post published articles. Until the mid-1980s, Dr. Healy says, the average patient who came to a psychiatrist or family doctor suffering from anxiety described periods of feeling tense and stressed. By the end of the decade, many came complaining of panic attacks. The marketing seems to have shaped the way people viewed their own experiences.

The idea of marketing a mental illness more than a drug was soon adopted by other pharmaceutical companies. Take the case of Paxil, an antidepressant that has gained important market share as an anti-anxiety drug.

In 1999, after the company now known as GlaxoSmithKline won FDA approval to market the drug for social-anxiety disorder -- excessive shyness and fear of social ridicule -- it hired a New York public-relations firm, which created the slogan, "Imagine Being Allergic to People." The campaign included bus-shelter ads across the United States picturing a sad-looking man playing with a tea cup. The drug company's name wasn't on the posters. Instead, people were asked to contact the Social Anxiety Disorder Coalition, which was a drug industry-funded group.

The firm sent out press releases and found well-spoken and photogenic patients for stories. In 2001, Paxil was approved for generalized anxiety disorder -- or excessive worrying, another anxiety disorder. Again, the company's public-relations machinery marketed what was a little-known ailment.

A spokesman for GlaxoSmithKline Inc. didn't want to discuss marketing of anxiety disorders. "The diseases our medication is approved to treat are all recognized by the broad medical community," Alison Steeves said.

Do the ad campaigns work? They do if sales figures are any indication. In the United States, sales of Paxil spiked by 25 per cent early in 2002, after the company spent $60-million (U.S.) on advertising. That kind of direct-to-consumer marketing is prohibited in Canada, but many Canadians see the ads on U.S. channels.

They are having an impact, Dr. Mintzes says. She and her colleagues recently published a paper in The Canadian Medical Association Journal that found that more than 87 per cent of patients visiting their family doctors in Vancouver had seen ads for prescription drugs, not quite as many as similar group in Sacramento, Calif.

While 7.2 per cent of the U.S. patients asked their doctor for drugs they had seen on television, 3.3 per cent of the Canadian patients did the same. In both cases, doctors generally gave patients the drugs they requested.

Some mental-health experts say marketing illnesses is a good thing. Neil Rector, head of the anxiety disorder clinic at the Centre for Addiction and Mental Health in Toronto, argues the PR campaigns have done a public service. As many as one in four people may suffer from an anxiety disorder at some point in their lives, he says, so getting people to ask their doctor about a potential problem can only be seen as a positive thing.

For years, people sick with anxiety suffered in silence. Today, depending on the diagnosis, treatment can help up to 80 per cent of them. "I believe the industry has done a very good job as raising awareness and getting a lot of people help that wouldn't otherwise have got it."

Jaques Bradwejn, the head of psychiatry at the University of Ottawa and psychiatrist-in-chief at the Royal Ottawa Hospital, is convinced that the disorders remain underdiagnosed. It isn't that too many are being treated, he says, but too few. He says he has yet to have a patient ask to be treated for an anxiety disorder who wasn't suffering from one.

The new Statistics Canada study found that as many as a third of people who report symptoms of mental illness don't seek treatment. When those with anxiety disorders do go to their doctor, many are reluctant to try medication, Dr. Bradwejn says.

That was the case with Mr. Baker. He didn't want to try an SSRI at first. Therapy is the first-line treatment patients like him often prefer as an alternative to medication.

A small group of patients with panic disorder would gather in the office of Diana Koszycki, research director of the Royal Ottawa's Anxiety Disorders Program (and Dr. Bradwejn's spouse), once a week for 12 weeks.

Dr. Koszycki would explain that panic attacks occur when the mind catastrophically misinterprets the body's physical signs of anxiety and stress, such as a heightened heart rate. "Think about how many times you thought you were having a heart attack," she asked Mr. Baker at the first session. "Did anybody die? Did anybody have a heart attack?"

She did drills with the patients, getting them to hyperventilate or jump up and down to bring on physical symptoms similar to those they experienced during their attacks.

The therapy is different for other anxiety disorders. For people with social anxiety who fear going out in public, Dr. Koszycki runs exposure therapy sessions: A group will go out to a restaurant; one by one, patients will draw attention to themselves by spilling water or sending food back.

But many people don't have access to therapy, especially if they live in rural areas. And when it is provided not by psychiatrists (who have medical degrees) but by psychologists such as Dr. Koszycki, it is not covered under public health care.

Private health plans can also limit access, says John Service, executive director of the Canadian Psychological Association: Many plans make it easier for patients to afford medication.

Barbara Everett, head of the Canadian Mental Health Association, Ontario, says in many cases, people have to pay out of pocket for therapy, which puts it out of reach of low-income Canadians. Many of the advice therapists give is low-tech, she says, yet effective -- to exercise, or to cut out caffeine. "But there is a presumption that mental illness is cured by pills."

Yet while therapy alone helps some people, studies do show that for most patients with anxiety disorders, it is most effective in combination with medication, Dr. Everett says.

After starting therapy, Mr. Baker was still having regular attacks -- including the one on the plane -- until he started taking Zoloft. He asked for it because he wanted to fly to Israel to attend a close friend's wedding. He managed the 22-hour flight, and even stayed in a hotel on the Lebanese border with a few friends, an adventure that would have been unthinkable before he started the medication.

He married his girlfriend, and they are now expecting a child. He knows he is lucky, and says he wouldn't have got better without the support of his close family and friends, or without treatment: "I got my life back."

It is hard to argue with success, but it is also hard to dismiss the fears of Dr. Healy and others who worry that doctors are medicating people who aren't truly ill. Pharmawatch's Janet Currie sees a tragic cycle in which new drugs come along by turns to treat troubles with sleep, moods and other fundamental human experiences. They are initially viewed as safe, but turn out to be addictive or carry serious side effects.

First there were barbituates, she says, then Valium and other benzodiazepines, now the SSRIs. "Every 20 years, we get sucked in. This is not a new thing. The drug companies exploit people's desire and need a panacea for a lot of normal life events."

It could be years before we have a clear perspective on the case of anxiety.

Meanwhile, Dr. Shorter says, the pharmaceutical companies are gearing up to market another mental illness. "It is absolutely fascinating to observe the interplay between science and commerce," he says. The buzz is, it will be hypochondria.

- Anne McIlroy is The Globe and Mail's science reporter

Anxieties for all seasons

Panic disorder. Frequent panic attacks that include chest pain, shortness of breath or choking sensations. Some people link the attacks to the situations in which they occurred, for instance driving or shopping, and severely restrict their activities to avoid attacks. It sometimes runs in families, is more common in women than in men, and affects up to 3.5 per cent of the population.

Social-anxiety disorder. Excessive shyness and fear of being humiliated in public. It can have a very early onset. Some patients recall going to kindergarten and being terrified of Show and Tell. It is more common among women than men, and may affect 8 per cent of the population.

Generalized anxiety disorder. Excessive and debilitating worry. Other symptoms include being easily irritable or uptight, having trouble sleeping, changes in appetite, a lot of aches and pains. It affects up to 3 per cent of the population and is more common in women than in men.

Phobias. Fears of specific things: Fear of snakes is the most common, followed by heights and flying, and then claustrophobia. Less common are fears of spiders, of being buried alive, or of bees. It is more common among women than men.

Post-traumatic stress disorder. Triggered by exposure to a traumatic event. Patients get flashbacks, nightmares. It is more common among women than in men.

Obsessive-compulsive disorder. Sufferers have fears, for example, of germs, which make them anxious. They relieve that anxiety with rituals such as hand-washing. It affects up to 1.5 per cent of the population. Equally common in women and men.

Sources: Diana Koszycki, research director of the Anxiety Disorders Program at Royal Ottawa Hospital; other interviews.


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