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BBC 1, 13 October at 10 15 pm

   The postmodern media critic Jean Baudrillard once asserted that the Gulf war did not happen, and was only a televised simulation of a war. By the end of Panorama's "The Secrets of Seroxat" my own grip on reality, never particularly strong, was faltering. This mental fragility disappointed me because I know quite a lot about selective serotonin reuptake inhibitors (SSRIs), having prescribed them, done research on them, and taken them. It may have been the nature of Panorama's "secrets" that undermined me. For example, the Shorter Oxford Textbook of Psychiatry notes both the key issues raised in the programme, namely that SSRIs, particularly paroxetine (Seroxat), can cause unpleasant withdrawal symptoms and that early in SSRI treatment restlessness and agitation might increase the risk of suicidal behaviour.

Despite this it seems likely that clinicians and patients aren't sufficiently aware of these problems. Panorama featured the video diary of Helen Kelsall, which gave a superb account of how hard it can be for some people to stop SSRI treatment. However, far darker things were in store and at the centre of the programme was the kind of horrifying tragedy that depression can visit on its victims and their families. After being on paroxetine for two days retired American oilman Donald Shell shot and killed three members of his family (including his 9 month old granddaughter) before taking his own life. Such disasters have happened before SSRI treatment and will occur after SSRIs have left the scene. However, the family blamed the paroxetine and sued.

Tragedies like this have multiple causes and it is impossible to know for sure to what extent paroxetine might have played a role. However, Panorama staged its documentary as a thriller with David Healy as hero, a kind of psychiatric Philip Marlowe, walking the mean streets down which a man must go. Healy, reader in psychological medicine at the University of Wales College of Medicine, was interviewed under true film noir conditions; half his face was in darkness while the rest was lit like a Rembrandt. Later we saw him driving alone, grim jawed and dauntless, through a dark winding tunnel to the Harlow headquarters of GlaxoSmithKline, a soulless Lubyanka overhung with swirling banks of cloud. Healy's quest "bordering on the impossible" was to identify crucial documents in a sealed warehouse packed with a quarter of a million pieces of paper. These documents, which held the closely guarded secret that SSRIs can cause adverse effects in healthy volunteers, could win the case for the Shell family. Healy eventually arrived in a dark cavern, lined with boxes. Suddenly, there was light. The rest was history and six million dollars to the plaintiff.

(Credit: BBC) View larger version (80K): [in this window] [in a new window]   Helen Kelsall's video diary showed how hard it can be to stop SSRI treatment

Of course, if there are heroes there must be villains and drug companies rival clearing banks and Saddam Hussein in public affection. Unfortunately for the company spokesmen, in the hyper-reality of television, choreographed anecdote will beat evidence based medicine every time. In the face of human misery and disaster, attempts to put depression, its treatment, and the risk of suicide in a statistical context only make you appear heartless and evasive.

Why are we sometimes slow to recognise drug problems and share our knowledge with colleagues and patients? Better information systems and the internet will help, but drug companies have two difficult missions: they must discover new, safe medical treatments and at the same time maximise profits for shareholders. These goals don't have to be incompatible because knowing about the possible problems of medications increases the likelihood that we will use them safely and well. However, company representatives can find it difficult to acknowledge weaknesses in their products. Perhaps the industry needs a new kind of marketing culture for a more informed and sceptical public.

Another factor peculiarly relevant to psychiatry is the stigma and misunderstanding that surround the illnesses and their treatment. For example, the narrator in the Panorama programme repeatedly referred to SSRIs as "happy pills," a term which trivialises depression and insults people taking medication. Now, who were the good guys again?

Footnotes

PJC has received fees for lecturing and advising a number of drug companies that market antidepressant drugs including SSRIs.

P J Cowen, professor of psychopharmacology. 

University of Oxford phil.cowen{at}psychiatry.oxford.ac.uk