Prescription Drugs:? Cure or Curse?
by Jodie Gilmore exclusively for infoholix.net
The report, ?Health, United State, 2004,? published by the National Center for Health Statistics, claims that 44 percent of? U.S. citizens take at least one prescription drug; for the elderly, the number climbs to more than 80 percent. In fact, an increasing dependence on prescription drugs permeates much of the civilized world. In an article by Dr. Tony Vendryes, the Jamaican Gleaner Online stated, ?We warn our youngsters and athletes about the danger of illegal drugs but turn a blind eye to the harsh reality that legally-prescribed drugs kill and harm vast numbers of innocent victims every day?Jamaican men, women and children are consuming more prescription drugs than ever before.?
We?ve been trained to trust doctors ? after all, they have gone through rigorous training and must obtain and maintain a license to practice medicine. And until recently, most people considered approval by the Federal Drug Administration (FDA) a sign that a drug was safe and effective. But many patients have abdicated their own responsibility to educate themselves, and often critical information about prescription drugs is not made available. The hard truth is, just because the FDA approves a drug, or a doctor prescribes a drug, doesn?t mean it is safe.
Are prescription drugs really a problem?
The phrase ?drug problem? usually conjures images of cocaine addicts, meth labs, empty syringes in the gutter, and crime waves. But illegal drugs are not the only ?drug problem? this world faces ? prescription drugs are fast becoming an even bigger health problem than illegal drugs. Even the Journal of the American Medical Association (JAMA) admits that the third leading cause of death in the U.S. is doctor-induced disease. Yep ? that?s right. Except for heart disease and cancer, the thing that poses the most risk to your health is doctors, with at least 225,000 deaths occurring per year ? just in hospitals! ?
Another study, published in 1998, rated adverse drug reactions as between the fourth and sixth leading cause of death in the U.S, saying reactions killed upwards of 100,000 people in 1994, and seriously injured another 2.2 million. This study also restricted its data to hospitals, and did not include prescription errors.
Other sources, such as Dr. Gary Null and colleagues, who published ?Death by Medicine? in 2003, estimate that more than 700,000 people die each year due to medical mistakes. (This number includes problems with prescription drugs, but also includes unnecessary surgeries, bedsores, and malnutrition, among other problems).
These are scary statistics, even if the exact number of deaths due to prescription drugs is impossible to pinpoint. The numbers cited above are almost certainly low, considering that most of the above data relates only to hospital deaths (what about people who die at home or at work?), and that many adverse drug reactions are not reported (either the patient fails to report them, or the doctor does). Even scarier is that most people seem unaware of the problem; and those who know about it try to keep it a secret.
This article explores the various facets that comprise the prescription drug problem, citing examples, exploring causes, and offering some possible directions for solutions.
What can go wrong?
First, why should people be concerned about prescription drugs? The answer is because they pose a number of serious health risks that are not properly explained to consumers by most doctors. These health risks include the following:
- adverse reactions (including death) to a single drug
- adverse drug interactions in ?drug cocktails?
- nutritional depletion
- prescription errors (from doctor, at pharmacy, or in hospital)
- off-label prescriptions
Let?s look at some examples of how each of these risks manifests itself.
??????????? Adverse reactions:? Most people consider antibiotics to be ?safe.? But one, Floxin? (one of a group of antibiotics called fluoroquinolones), has an overall 11 percent adverse reaction rate and is well-known for causing serious side effects including tendon ruptures and neuropathy issues, seizures, anxiety, cognitive changes, depression, dream abnormality, and hallucinations (among others). Other fluoroquinolones include Cipro?, Penetrex?, Maxaquin?, and Noroxin?. In August 2006, the FDA received a request for a black box warning for all fluoroquinolones. According to an article by Dr. Jay S. Cohen in the Annals of Pharmacotherapy, ?fluoroquinolone-associated demyelinating peripheral neuropathies have not previously been appreciated or listed in the drug-prescribing information.? A recent check of the listed side effects of Floxin revealed that tendonitis/tendon rupture was listed ? but was buried in the ?worldwide post-marketing? section, which is much farther than most consumers would read.
Another commonly prescribed group of drugs are psychiatric drugs ? and they are increasingly being prescribed for children, with horrific results. In well over half of the school shootings that have occurred since 1998 (and maybe in all of them), the child wielding the gun was on psychiatric drugs. ?
Great Britain’s Department of Health issued a report that said studies based on more than 1,000 children show the rate of self harm and potentially suicidal behavior increases in those under 18 taking Paxil?, one of several SSRI (selective serotonin reuptake inhibitors) antidepressants (other SSRIs include Prozac?, Luvox?, and Seroxat?). British health regulators recently issued a warning that said ?It has become clear that the benefits of Seroxat in children for the treatment of depressive illness do not outweigh these risks.? The FDA and Irish health officials have also issued a similar warning for Paxil.
According to a story on USA TODAY Online, some antipsychotic drugs can also be dangerous when given to children. The article stated that ?[A] study of FDA data collected from 2000 to 2004 shows at least 45 deaths of children in which an atypical antipsychotic was listed in the FDA database as the ?primary suspect? for cause of death. No one seems to be taking notice of such data, however. In fact, during the period from 1995 to 2002, said the article, ?outpatient prescriptions for kids ages 2 to 18 leaped fivefold ? from just under half a million to about 2.5 million,? which means about 4 out of every 100 children are taking such drugs, despite the fact that the drugs are not labeled for pediatric use.?
Painkillers are also commonly prescribed. Most people know that NSAIDs such as ibuprofen can cause stomach bleeding. And in 2004, another painkiller, Vioxx?, skyrocketed to the top of the media coverage. Vioxx was taken off the market in 2004, because researchers discovered that long-term users of Vioxx (25 mg/day) showed an increase in the incidence of heart attacks and strokes. After Vioxx was pulled from the U.S. market, other countries, such as New Zealand and Germany, restricted the use of Vioxx and similar drugs (called COX-2 inhibitors). Dr. David Graham, an employee of the FDA and the main ?whistleblower? on the dangers of Vioxx, said in an interview that because the FDA ignored data that pointed to increased risk of heart attack in users of Vioxx, that ?the FDA is responsible for 140,000 heart attacks and 60,000 dead Americans. That?s as many people as were killed in the Vietnam War?[Americans] should be screaming because this can happen again.?? Estimates place worldwide deaths caused by Vioxx at 150,000 to 200,000 ? but these figures have not been confirmed officially.
Indeed, it seems Dr. Graham was right in his warning that it ?could happen again.? An FDA advisory panel recently voted to approve Vioxx?s return to the market, and Merck (the manufacturer of Vioxx) is seeking FDA approval for a very similar drug, Arcoxia? (already available in 62 countries worldwide).
Another drug, Tysabri?, was recalled in 2005, after only about a year of being on the market. Why?? According to the warning now required to be on the drug, which was reinstated in 2006, ?TYSABRI increases the risk of progressive multifocal leukoencephalopathy (PML), an opportunistic viral infection of the brain that usually leads to death or severe disability. Although the cases of PML were limited to patients with recent or concomitant exposure to immunomodulators or immunosuppressants, there were too few cases to rule out the possibility that PML may occur with TYSABRI monotherapy.?
Some people are now asking ?is no drug too dangerous for FDA approval?? and ?Can doctors and patients competently weigh the risks versus the benefits of such drugs??
??????????? Drug cocktails: According to the National Center for Health Statistics, 16.5 percent of Americans take three or more prescriptions at one time. This is often referred to as a ?drug cocktail.? Each of these drugs has its own effect on the body ? but together, the potential for danger is even greater, as many drugs interact negatively with one another. The online reference, www.drugdigest.org, which lists known drug interactions, says that there are at least 11,500 potential prescription drug interactions, then adds this caution: ?Not all drug interactions are known or reported in the literature, and new drug interactions are continually being reported.? Some drugs are worse than others in this regard. JAMA recently reported that ?there are probably more potential drug interactions between warfarin and other prescription drugs than [with] any other prescription product.? Warfarin (aka Coumadin?) is a blood thinner commonly prescribed for heart patients.
Adding to the potential danger are possible interactions between prescription drugs and ?natural? substances like herbs. In countries where treatment with herbal medicines is common, such as Ethiopia, these sorts of interactions pose a significant threat. Fekadu Fullas, Rph, Phd, has written a book, Interactions of Ethiopian Herbal Medicines and Spices with Conventional Drugs: A Practical Guide. Other researchers should follow Fallas? example and publish similar guides for other countries.
??????????? Nutritional depletion: Some prescription drugs pose a different kind of danger. Instead of directly killing you, or directly causing behavioral anomalies, they interfere with the natural levels of various nutrients or other substances in your body. This depletion, over time, may make it more likely that you will succumb to other ailments besides the one the prescription drug was supposed to fix. The simplest and possibly most common depletion is the effect of antibiotics on the digestive system. Most antibiotics can cause diarrhea, but many people don?t know why that is. In most cases, it is because the antibiotics are doing their job ? only too well. They kill off not only the harmful bacteria that is making you sick, but also the beneficial ?flora and fauna? that naturally inhabit your digestive tract; this lack of normal digestive bacteria, in turn, causes diarrhea (it can also cause women to be prone to yeast infections). The simple precaution of taking a ?probiotic? ? usually acidophilus bacteria, and sometimes others as well ? along with the antibiotic can generally prevent diarrhea. But a great many people are never advised to do this by their doctors.
Antibiotics are generally taken for a short time, and digestive bacteria can usually repopulate themselves without aid ? but there are other, more long-term and dangerous depletions caused by prescription drugs.? Statins, used to lower cholesterol, deplete or interfere with the absorption of several chemicals necessary for continued health. In particular, statins are well-known for causing severe muscle damage (rhabdomyolysis), extreme weakness, muscle pain, severe memory loss, liver and kidney problems, and depletion of CoQ10.
Some blood pressure medicines can also significantly reduce the levels of CoQ10, which helps maintain cellular energy and is an important antioxidant. Many drugs, including some blood pressure medicines, estrogen replacement therapy, and antibiotics can deplete various B vitamins (e.g., B-2, B-6, and B-12).
Because doctors are not highly aware of these side-effects of the drugs they prescribe (after all, the pharmaceutical companies do not trumpet the information from the rooftops), many patients assume that the hair loss, memory impairment, weakness, depression, and a host of other symptoms are part of what the doctor is treating ? not an effect of the treatment itself!
??????????? Prescription errors: ?According to the Nov. 14, 2006 issue of the Jamaican Gleaner Online, the president of the Nurses Association of Jamaica (NAJ), Edith Allwood-Anderson, said ?Medication errors by local doctors are a cause for concern.? She also stated that ?The standard of prescription orders is insufficient and needs to be monitored.?
A 2004 study in Norwich, England revealed that 24 critical-care units, over a four-week period, wrote an average of approximately 15 prescriptions per patient. Fifteen percent of those prescriptions contained at least one error; 19.6 percent of those errors were considered ?significant, serious or potentially life threatening.?
Even if the doctor writes the correct prescription, things can still go wrong at the pharmacy.
One tragic example is the death of five-year-old Brendan Ward, who died in 2004 due to a ?typo? in his prescription for imipramine, a medication that helps with bedwetting. The technician typed ?250 milligrams/teaspoon? instead of ?50 milligrams/teaspoon.? Imagine the horror and grief when Brendan?s mother found him stone-cold dead in his (dry) bed the next morning.
The National Association of Boards of Pharmacy estimates that in 2004, incorrect prescriptions caused as many as 7,000 deaths in the United States. Of the more than 4 billion prescriptions filled each year, as many as 5 percent are incorrect. Exacerbating the problem is a trend toward a decreasing number of pharmacists ? a recipe for more errors than ever.
??????????? Off-label prescriptions: It is common practice for doctors to prescribe medications for conditions for which the medication is not approved by the FDA. Sometimes, this is a good idea ? if clinical observation and scientific studies indicate such a use poses concrete benefits and little risk to the patient. The problem is, according to a study from the Stanford University School of Medicine, doctors don?t always use such criteria to prescribe a drug ?off label.?
The study looked at prescriptions for 160 drugs during 2001. Out of a total of 725 million prescriptions, 21 percent were off-label. What?s worse, 73 percent of these off-label prescriptions had little or no evidence that the off-label use would be of benefit. For example, 83 percent of the prescriptions for a drug called gabapentin (also known as Neurontin?) were off-label; but in 66 percent of these cases, the scientific evidence (such as that published in DRUGDEX) did not support gabapentin?s use.
Sometimes off-label prescriptions don?t just not work, they are downright dangerous. With regard to prescribing psychiatric drugs for children, John March, chief of child and adolescent psychiatry at Duke University School of Medicine, says ?We have no evidence about the safety of these agents or their effectiveness in controlling aggression. Why are we doing this??
As another example, Gabitril? is a drug that is used successfully to treat some forms of epilepsy. But this drug is also commonly prescribed for other conditions, such as psychiatric illnesses ? with an unexpected effect: at least 30 patients for whom Gabitril was prescribed, but who did not have epilepsy, suffered seizures.? Now, these patients? doctors were probably as dismayed as their patients at the negative effect of the prescription ? and who would have thought a medicine used to treat seizures would cause them? But this just underscores how unsafe and/or untested many prescription drugs are, and illustrates the dangers of off-label prescriptions.
??????????? Abuse: Prescription drugs are also becoming the drug of choice for teenagers seeking a quick buzz, according to the 2003 Monitoring the Future survey, conducted by the University of Michigan Institute for Social Research. The survey revealed that one in ten high school seniors had used Vicodin? (without a prescription). Similar usage numbers were revealed for Ritalin?, while 6 percent had used tranquilizers (such as Valium?). Four and a half percent had used OxyContin?, a powerful painkiller. ?These drugs can be highly addictive if they?re used on an ongoing basis, and the person can become physically, psychologically and behaviorally addicted to them,? said Maher Karam-Hage, M.D., who is medical director of the Chelsea Arbor Treatment Center (operated by Univ. of MI).
As more and more parents fall into the trap of listening to the pharmaceutical companies? and doctors? mantra of ?you need more drugs!? they are unwittingly putting their children at risk by storing these theoretically ?safe? medications in their homes.
Where to lay the blame?
It is tempting to lay the blame for this whole mess at the feet of one or other of the players ? the pharmaceutical companies, the FDA, or the doctors. And each of these definitely deserves some of the blame.
??????????? Big Pharma: Pharmaceutical companies often downplay research trials that do not show the drug in question in a positive light. Statin drugs, for example, are marketed as lowering cholesterol which in turn is supposed to lead to better cardiovascular health. But in September 2004, JAMA published a study that showed that high doses (80-mg/d) of one statin drug (simvastatin, better known as Zocor?) not only failed to lower risk of cardiac events (heart attack, stroke, or cardiac death), it also caused an unacceptable high rate of myopathy. And in the analysis of the study, it was stated that
[I]n 1997 the manufacturer undertook a development program to study 2 higher doses of simvastatin (80 mg/d and 160 mg/d). ?Although a favorable report appeared in the medical literature, development of the 160-mg/d dose was abandoned due to high muscle toxicity. Although never reported in the scientific literature, the financial community was informed that the rate of muscle-related symptoms was 5.7% for the 160 mg/d dose?
There are several lessons to be learned from these events. The failure of the 160-mg/d dose of simvastatin and the enhanced toxicity ? should probably have served as a warning that the 80-mg/d dose of simvastatin might border on a toxic threshold. Relatively minor differences in the rate of elimination, a low body mass index, mild renal insufficiency, or other unknown factors appear capable of pushing simvastatin blood levels into the toxic range. The failure to publish the actual results of studies using the 160-mg/d dose (negative publication bias) arguably prevented the medical and scientific community from fully appreciating the myopathic potential of high-dose simvastatin.
Of course, you can?t single out cholesterol drugs. According to Dr. Julian Whitaker,
A minimum of five studies on the use of [Paxil, an antidepressant] for children and adolescents have been conducted, and four of them showed that not only did it not work but also suggested increased risk of suicide. However, just one study ? the only one that showed partially favorable result ? was published.
Dr. Richard Friedman, director of the psychopharmacology clinic at Weill Medical College of Cornell University, wrote in the New York Times, ?For too long, drug companies have been allowed to tell us only the good news about their products. Now we’re ready for the whole story.?
In late October 2006, GlaxoSmithKline PLC (based in London) agreed to a $63.8 million settlement for claims that it allegedly promoted its antidepressant drug Paxil for use by children and adolescents while withholding negative information about the medication’s safety and effectiveness. Although GlaxoSmithKline denies the lawsuit?s claims, they settled to avoid any further litigation costs.
A British newspaper, The Independent, reported in June 2005 that ?vital data on prescription medication found in millions of British homes has been suppressed by the powerful U.S. drug regulators, even though the information could potentially save lives.? The paper said 28 pages of data had been removed from the FDA files.
In addition to ?negative publication bias,? the pharmaceutical companies also seed governmental and research groups with panel members who have financial ties with the pharmaceutical companies themselves. Talk about conflict of interest!? Is it surprising, for instance, that an ?expert? panel voted for new, lower cholesterol guidelines (thereby creating a new pool of cholesterol-lowering drug users), when eight out of the nine members of the panel were involved financially with the statin drug-producing companies?
Dr. Whitaker claims that ?three quarters of the clinical studies in the top medical journals such as The Lancet, The New England Journal of Medicine, and JAMA are commercially funded.?
Pharmaceutical companies also market their drugs aggressively. Now, there?s nothing illicit about marketing, per se. But two marketing techniques used by the drug companies are of questionable ethics. One is their direct-to-consumer ads, such as on TV. These ads clearly portray certain drugs? benefits, while downplaying risks. The list of side effects is often read at ?auctioneer? speed right at the end of the commercial, making it hard to hear and understand. Prior to 1997, direct-to-consumer advertising by drug companies was illegal.?
Drug companies also target doctors specifically, using a variety of techniques ranging from free samples to ?continuing education? classes that push certain drugs to flying doctors to exotic locations for ?conferences? about a particular drug. Doctors, of course, claim they are unaffected by all the attention paid to them by the drug companies ? that they prescribe based on science not advertising. However, in 2005, a small study published in JAMA showed an interesting result:? people who specifically named a drug (by referring to a TV commercial for Paxil) during a doctor?s visit were five times as likely to be given a prescription for antidepressants than those who did not name the drug. One could infer from this study that drug ads affect consumers, who in turn affect doctors? decisions ? possibly leading to over-prescription of the advertised drugs.
Matthew Hollon, an internist at the University of Washington, called direct-to-consumer advertising by drug companies a ?haphazard approach to health promotion that is driven primarily by the pharmaceutical industry?s interest in turning a profit.? Hollon also claimed that 80% of physicians believe that direct-to-consumer drug ads cause patients to request medications they do not need.
A study conducted at Brandeis University and published in Psychiatric Services claims that after direct-to-consumer advertising was legalized in 1997, pharmaceutical companies increased their TV advertising budget 600 percent, reaching a total of $1.5 billion in 2000. During a similar time frame, the incidence of prescriptions of psychotropic drugs (such as those used to treat ADHD and depression) increased significantly. By 2001, said the study, ten percent of doctor?s office visits by adolescent boys resulted in a prescription for such a drug. According to a June 2006 article in The Guardian (a British publication), the marketing budget for drug companies worldwide in 2005 was $60 billion ? twice as much as they spent on research.
Pointing to the fact that misconduct on the part of drug companies is not just a U.S. issue, the world federation of consumer organizations, called Consumers International, wrote in its report, ?Branding the Cure: A consumer perspective on Corporate Social Responsibility, Drug Promotion and the Pharmaceutical Industry in Europe,? that ?irresponsible marketing practices form a serious, persistent and widespread problem among the entire pharmaceutical industry.??
??????????? Federal Drug Administration: The FDA takes its share of the blame, as well. Dr. Graham said flatly that the FDA is ?serving industry rather than the public.? In other words, it is a common opinion that the FDA is in the pocket of the drug companies, and no longer considers the American people its primary client or concern. Writing for NewsTarget.com, columnist Mike Adams wrote in? June, 2006 that the FDA had passed a Final Rule that states ?consumers can no longer sue drug companies for the harm caused by any FDA-approved drug, even if the drug?s manufacturer intentionally misled the FDA by hiding or fabricating clinical trial data.? Although this blatant power grab by the FDA is unlikely to go unchallenged ? it has little or no basis in law ? it certainly clearly delineates the FDA?s position of being a cozy bedfellow of ?big pharma.?
??????????? Physicians: Doctors, too, can be at fault for inculating or exacerbating some of the problems with prescription drugs. For example, GlaxoSmithKline (which is Great Britain?s largest drug company, and the second-largest in the world) is being investigated by authorities in Germany and Italy for allegedly corrupting doctors by distributing illegal gifts worth up to E228 million during the years 1999 to 2002. Now, while you could make the case that this is a drug company problem, you can just as easily make the case that it is a doctor problem ? they didn?t HAVE to accept those gifts!
What?s a patient to do?
But laying the blame at others? doors is not the whole answer. Citizens ? whether of the U.S., Britain, or other countries, have a responsibility to educate themselves and to demand changes in the obviously faulty prescription drug system. Here are some positive steps citizens can take to safeguard their own health and the health of others:
- Work with government and advocacy groups to untangle the regulatory aspect of drugs from the research and marketing aspects.
- Support legislation that requires drug companies to publish the results from all studies in a public database.
- Push for more user-friendly drug documentation that clearly lists the side-effects of drugs (in something larger than 4-point type); encourage doctors to discuss these possible health threats with their patients so that patients can make an informed benefit vs risk decision.
- Similarly, work to separate the prescribing process (doctors) from the marketing tentacles of the pharmaceutical companies.
- Work to change from a ?fix the symptoms? health perspective to a ?find the causes? perspective.
- Protect yourself from prescription errors by reviewing the prescription with your doctor, and comparing the prescription to the bottle of medication you receive from your pharmacist.
- Educate yourself about your condition and all possible treatments ? prescription drugs and otherwise.
- Learn to ask your doctor for supporting evidence when he or she prescribes a drug for a specific condition, especially if it is an off-label prescription.
One way to educate yourself about the dangers of prescription drugs and the relationship between Big Pharma, doctors, and the FDA, is to read books. There are a number out there; here are just a few to get you started:
- Overdosed America by Dr. John Abramson, M.D.
- The Drug-Induced Nutrient Depletion Handbook by Ross Pelton et al.
- Bitter Pills: Inside the Hazardous World of Legal Drugs by Stephen Fried.
- The Truth about the Drug Companies: How They Deceive Us and What to Do about It by Dr. Marcia Angell
Note: None of the information in this article is intended to be or should be construed as medical advice.
? By Jodie Gilmore 2006.
Reprint of web pages are only allowed with explicit permission. Please request our permission by emailing us with a complete description of the intended use.
 Starfield, Barbara. ?Is US Health Really the Best in the World?? Journal of the American Medical Association (JAMA) 284 (July 26, 2000): 483-485.
 Lazarou , Jason; Pomeranz, Bruce H.; and Corey, Paul N. ?Incidence of Adverse Drug Reactions in Hospitalized Patients: A Meta-analysis of Prospective Studies.? JAMA. 279 (April 15, 1998): 1200-1205.
 Online:? http://www.fqresearch.org/hrg1781.htm
 Cohen, J.S. ?Peripheral neuropathy associated with fluoroquinolones.? Annals of Pharmacotherapy 35 (December 2001): 1540-1547.
 Whitaker, Julian. Health & Healing 15 (May 2005): 1.
 Elias , Marilyn. ?New antipsychotic drugs carry risks for children.? USA TODAY online, May 2, 2006: http://www.usatoday.com/news/health/2006-05-01-atypical-drugs_x.htm.
 Whitaker, Julian. Health & Healing, 14? (April 2004): 5.
 Ridley, S. A., et al. ?Prescription errors in UK critical care units.? (Anaesthesia 59 (December 2004): 1193-1200. You can see the abstract of this article online at http://pt.wkhealth.com/pt/re/anesb/abstract.00000524-200412000-00009.htm;jsessionid=FgvLhd1BG1gynC2dvFC246083MmJ8ShC1hQvQRklttP2J2NDCKh3!-676649506!-949856144!8091!-1.
 Radley, David C.; Finkelstein, Stan N.; Stafford, Randall S. ?Off-label Prescribing Among Office-Based Physicians.? Archives of? Internal Medicine 166 (May 8, 2006): 1021-1026.
 USA TODAY, ibid.? See note #6.
 Nissen, Steven E. ?High-Dose Statins in Acute Coronary Syndromes.? JAMA 292 (Sept. 15, 2004): 1365-1367.
 Whitaker, Julian. Health & Healing 14 (Dec. 2004): 2-3.
 Cohen, J.S. ?Suicides and Homicides in Patients Taking Paxil, Prozac, and Zoloft: Why They Keep Happening — And Why They Will Continue.? Online: http://www.medicationsense.com/articles/oct_dec_03/suicides_homicides.html
 Whitaker, Julian. Health & Healing, 16 (June 2006): 2.
 Kravitz, Richard L.? Influence of Patients? Requests for Direct-to-Consumer Advertised Antidepressants: A Randomized Controlled Trial.? JAMA.293 (April 27, 2005):1995-2002.
 Parks Thomas, Cindy; Conrad, Peter; Casler, Rosemary; and Goodman, Elizabeth. ?Trends in the Use of Psychotropic Medications Among Adolescents, 1994 to 2001.? Psychiatric Services 57 (Jan. 2006): 63-69.
 Psychiatric Services, ibid.
 Boseley, Sarah. ?Drug firms a danger to health – report.? The Guardian online, June 26, 2006: http://www.guardian.co.uk/medicine/story/0,,1806084,00.html
 ?Branding the Cure: A consumer perspective on Corporate Social Responsibility, Drug Promotion and the Pharmaceutical Industry in Europe.? Consumers International, June 2006: page28. You can view the report online at http://www.consumersinternational.org/Shared_ASP_Files/UploadedFiles/ECD91B6F-FE37-45C0-AE34-898BFB39C700_BrandingtheCure-fullreport.pdf