Dr. Ronald A. Ruden practices medicine in a suite that resembles a vast underground hangar, below a high-rise on the Upper East Side. His waiting room is furnished with small café tables and colorful Macintosh computers, so idle patients can surf the Web. Ruden and his partner run one of the largest practices in the city. He personally sees nearly 200 patients a week, compared with 50 for most doctors, he says.
Ruden is an internist, not a psychiatrist, but on top of his bustling practice, he managed in his spare time to publish a book, The Craving Brain, sketching out some unconventional ideas about the roots of addiction. He is also an enthusiastic prescriber of antidepressants.
A few months ago, a woman who works in his office -- I will call her Heidi -- came to Ruden seeking help. A middle-aged immigrant, Heidi told him she had always been a worrier. Recently, though, her anxiety had risen to a new pitch. She found herself rechecking minor tasks three or four times to be sure they were done. Sometimes at home in her apartment in Queens, she grew so nervous that her heart raced; she'd board a bus back to the office just to make sure that everything was in order.
After a brief consultation, Ruden stepped into the hallway, reached into a cabinet, and took out some bulky blue-and-yellow cardboard packets labeled CELEXA.
Only two years ago, no one in the U.S. had heard of Celexa. But since its launch in September 1998, it has captured over 13 percent of new prescriptions in the $6.3 billion market for its class of antidepressants, which also includes Prozac, Zoloft, and Paxil. And Celexa is the only one whose market share is growing.
"You may have reason to wonder: Is your doctor doing what's right for you, or for him?"
The drug has achieved this spectacular growth without any decisive advantage over its predecessors. "With these antidepressants," says Ruden, "you have to understand that we really don't know what we are doing. We know these drugs work, but we don't know exactly how, and each one is a little different."
The reason for Celexa's stunning success is not science but marketing. Drug-industry consultants Scott-Levin say U.S. pharmaceutical companies spent about $10 billion last year on drug promotions. Most of that -- $9 billion -- went toward marketing to doctors (about $12,000 for each doctor in the U.S.). Drug makers command an army of more than 68,000 salespeople, one for every eleven doctors in the U.S. While pharmaceutical companies justify high drug prices by pointing to astronomical research and development costs, many who study the industry say drug companies spend more on marketing and promotions, especially for drugs like Celexa.
Celexa is what is known in the business as a "me-too" drug. The Medical Letter, a nonprofit newsletter that evaluates new drugs, pronounced that Celexa had "no advantage" over Prozac, Zoloft, and Paxil. All adjust the level of serotonin in the brain. All four improve the mood of about 65 percent of the moderately depressed patients who take them.
Ruden has been prescribing Prozac for years. "A familiar drug gets to be like an old friend," he says. He is on good terms with Ashleigh and Julie, the Prozac drug reps who visit him from Eli Lilly & Co. Like other busy doctors, Ruden is showered with small gifts and invitations to events at fancy restaurants. Once, a sales rep called to invite him and his wife to a Yankees game. Ruden told her, "Look, just give me the tickets," and he took his family instead. There are so many new drugs appearing all the time, Ruden says, that he has to rely in part on the drug salespeople to keep him up-to-date. But he says he threatens them if they aren't forthright: "Tell me the warts," he warns them. "If I prescribe something, and its wrinkles -- its possible problems -- catch me by surprise, I will never prescribe your drug again."
Michelle and Tina, new reps from Forest Laboratories promoting Celexa, filled his cabinets with "a ton of free samples." They told him Celexa was "the cleanest" antidepressant, with a "favorable side-effect profile." And they suggested that Celexa may be less likely to bring on Prozac's most infamous side effect -- the tendency to sap the libido and inhibit orgasm.
Ruden was skeptical -- he was convinced the whole class of drugs shared that drawback -- but he tried the new pills on a few patients. He found that Celexa seemed a little less "activating" than Prozac, which sometimes causes agitation, he says. Heidi took the samples Ruden gave her, and a prescription for one 20-mg. capsule a day. A few months later, Heidi says, Celexa restored her life to normal: "I can relax, watch TV, fall asleep. I thank Dr. Ruden from the bottom of my heart. Actually, I should thank the sales reps, Michelle and Tina, too, next time they're here."