Feature

Inside the Happiness Business

Questions about Celexa's potential for sexual side effects come up a lot, Backer says. "Now, we have some data to suggest that Celexa's sexual side effects may be a little bit less than the others', but that is not something that we are making our main selling point; we don't want to overpromise," she says. "We tell them some physicians say that Celexa is somewhat less likely to lead to sexual dysfunction, but it is hard to judge, and it is different with every patient."

The idea that Celexa may be less likely to cause sexual dysfunction, however, has come across loud and clear. As soon as she heard the name Celexa, one New York psychotherapist's first response was "Oh, yes, the one with fewer sexual side effects." Amy Brodkey, a Philadelphia psychiatrist, says she doesn't see drug reps but that her colleagues have picked up the same idea from their Celexa reps. "The current evidence suggests that it doesn't cause weight gain or sexual dysfunction to the same extent," says Dr. Steven Erle, an Upper East Side psychiatrist who not long ago enjoyed dinner at the restaurant Daniel with a Forest drug rep. "It seems likely that when we know more, the rate of sexual dysfunction won't be nearly as high as with Prozac or Paxil."

Forest's strongest evidence for Celexa's advantages on the sexual front were presented at the annual meeting of the American College of Neuro-Psychopharmacology in December. Dr. Marcel Waldinger, of the Hague, reported the first head-to-head comparison of the sexual effects of Celexa and another antidepressant, in this case Paxil. Thirty men who suffer from premature ejaculation -- ejaculating an average of about 22 seconds after entering their partners -- agreed to participate in a blind test. While having sex, their partners used stopwatches to time the men's orgasms. Paxil delayed ejaculation until after about 170 seconds on average. But the men on Celexa still lasted only about 44 seconds, a lag the authors call "clinically irrelevant." The results, Waldinger said in a Forest press release, "should be useful to clinicians, both when treating men who complain of premature ejaculation, as well as when trying to avoid unwanted sexual side effects in patients with depression."

Failing to inhibit premature ejaculation, however, says little about Celexa's potential to inhibit orgasm in other people. "That just doesn't follow," says Dr. William Appleton, a professor of psychiatry at Harvard and author of Prozac and the New Antidepressants. "I haven't found that Celexa has fewer sexual side effects, but in any event, premature ejaculation is not the issue."

Robert Goodman, an internist who works at Columbia-Presbyterian, tried for years to chase the drug reps out of his clinic. "What really annoyed me was physicians' willingness to be bribed," Goodman explained to me over a plate of rice and beans at a Dominican restaurant near the hospital. "Physicians, as a group, are pretty well off, but at professional conferences, they will wait in line a half an hour for a can of tennis balls or a free clock from a drug company. Then they'll send their kids back up to get another!"

Finally, he decided to retaliate. He ordered pens, T-shirts, and coffee mugs of his own. He labeled them NO FREE LUNCH: JUST SAY NO TO DRUG REPS. Then he set up www.nofreelunch.org, an online compendium of facts and research about the influence of drug companies on medicine.

Goodman intended the site for health-care providers, but it makes disconcerting reading for patients. In one Harvard Medical School study, 85 doctors answered questions about two heavily marketed drugs, one for senile dementia and one for pain. Almost all the doctors said they relied only on academic research, but 71 percent repeated inaccurate information presented only in ads for the dementia drug. Nearly half the doctors fell into the same trap with the pain reliever.

Another surprising figure: The $10 billion the industry spends on marketing to doctors is more than the federal government pays for medical training. "It is a colossal waste!" Goodman says. "But the most comical thing is doctors' attitudes. You will never hear a physician say, 'This is influencing me.' They are just so arrogant and naïve," Goodman says.

Dr. Ruden, the busy physician on the Upper East Side, says he has been happy with Celexa's results. And he insists that marketing has "no impact" on his practice. "No one in their right mind would admit that it could have an impact on their prescribing. You must really avoid the concept of being bought off by a dinner," Ruden says. "I mean, I can afford to go to any place I want."

When one drug rep recently invited him to a fancy dinner, he told her, "Here is what you can do. Buy me a Mercedes and put the name of your drug on the side. I will drive it around for you." A week later, she brought him a small present. When Ruden tore off the wrapping paper, he found a Hot Wheels toy Mercedes with the name of the drug on the side. "Size matters," he told her. They both had a big laugh.