Side Effects: A Prosecutor, a Whistleblower, and a Bestselling Antidepressant on Trial

by Alison Bass

  NONE OF THIS, however, was in the air in 1988, when Prozac arrived in the United States. Many clinicians, Teicher among them, were eager to try a new weapon in the fight against depression, particularly a "clean" drug that appeared to target only one transmitter system in the brain with no serious side effects.

  By the spring of 1988, Martin Teicher had been at McLean for six years, first as a psychiatric resident and then as a staff psychiatrist and neuroscience researcher. Along the way, he had picked up a number of private patients, such as Ms. D., whom he saw in his office on the second floor of the Wyman House, a stately brick building tucked away in the rear of the campus (a brisk ten-minute walk from the Mailman Research Center) and named after Dr. Rufus Wyman, the first superintendent of the McLean Asylum. At thirty-six, Teicher, known as Marty to his colleagues, was a compact, soft-spoken man with wavy black hair and a serious demeanor. His colleagues admired him for his innovative approach to research, his passion for learning, and his willingness to put in long hours. At McLean, it was expected that an ambitious young psychiatrist would see hospital patients, conduct lab research, and have his own private practice. But Teicher eclipsed even those expectations. He was a workaholic, devoted to his patients, his research, and his career. In July 1988, his hard work would pay off with his promotion to director of the hospital's newly endowed developmental biopsychopharmacological research program.

  When Teicher had first come to McLean, fresh out of Yale Medical School, he had been too busy what with thirty-six-hour shifts crammed with clinical care and lab work-to dwell on the incongruity between the hospital's beautifully manicured setting and the strange ailments of the patients treated there. With its mix of handsome colonial and Jacobean revival buildings, the 232-acre campus could easily have been mistaken for an Ivy League university. Over the last century, McLean had become famous for catering to wealthy Brahmins and celebrities in need of "rest" And yet the patients Teicher saw in his daily rounds were worlds away from such highbrow clientele. They suffered all manner of mental torment. One woman believed that worms and maggots were eating her brains and repeatedly bashed her head against the wall in an attempt to rid herself of the vermin. Others lay coiled in fetal positions for hours at a time, unable to move a limb. One of his private patients had multiple personalities, including one flirtatious alter ego named Sue, who fantasized about having sex with Teicher, and a second persona who gruffly demanded that she kill herself.

  Teicher was fascinated by these patients, even more by the question of how the wiring in their brains could have become so crossed and tangled. And there was also the satisfaction in being on the staff of New England's preeminent psychiatric hospital, with a faculty appointment at Harvard Medical School.

  ON THAT LATE spring afternoon in 1988, Teicher had returned to his lab at the Mailman Research Center to check on an experiment before leaving for the day. But he couldn't concentrate; he was too distracted by what his patient had told him that afternoon. It had been three months since he had started Ms. D. on twenty milligrams of Prozac. When her depression didn't abate, he followed standard medical procedure and gradually increased the dose first to sixty and then to eighty milligrams. Her mood, however, continued to worsen, and she started drinking again after eight years of sobriety. Even more worrisome to Teicher, she became preoccupied with thoughts of suicide.

  During that day's therapy session, she told him that she was thinking of buying a gun to kill herself with. She referred to Prozac as that "deadly drug" Teicher knew that his patient had attempted suicide on two previous occasions, but he saw those overdoses largely as calls for help: she had phoned someone almost as soon as she crammed the pills in her mouth.

  This time, however, she confided to Teicher that she was sure that Prozac would enable her to finish the job. As Teicher listened with mounting unease, he suddenly remembered that two of his other patients on Prozac had also exhibited a growing preoccupation with suicidal thoughts. And then it struck him: What if this was something more than a worsening of their depression? What if this obsession with self-destructive thoughts (one of his other patients had even put a loaded gun to her head) had something to do with the antidepressant itself? There is something very weird going on here, Teicher thought as he locked the door to his lab. He would have to ask around and see if any of his colleagues had had similar experiences with the new "wonder" drug.

  IT WOULD TAKE Martin Teicher another six months to begin to understand what he was seeing in his patients. In the fall of 1988, he and two colleagues at McLean began putting together a case study of six patients, including Ms. D., none of whom had been seriously suicidal before taking Prozac. After taking the drug for several weeks, all of them developed an intense and in some cases violent preoccupation with suicide. One of these six patients, a nineteen-year-old college freshman, repeatedly lacerated herself on her forearms with a knife, requiring emergency room care. She was taken off Prozac, and her self-destructive urges abated. Teicher and his coauthors, Dr. Jonathan Cole, the head of psychopharmacology at McLean, and Carol Glod, a respected nurse-practitioner at the hospital, observed the same phenomenon with the other five patients in their case report. They submitted their clinical observations to the American Journal of Psychiatry. By January 1989, the prestigious journal had promised to publish the case report with some revisions. In May of that year, Teicher took a break from revising the paper to attend the annual meeting of the American Psychiatric Association in Montreal. He was eager to hear about other practitioners' experiences with Prozac.

  As TEICHER TOOK the wide concrete steps of the Montreal Convention Center plaza two at a time, a flurry of activity in one corner of the plaza caught his eye. A small group of people were chanting and waving signs. Some signs read PROZAC KILLS; others, PROZAC = VIOLENCE. As Teicher drew closer, he noticed a large man standing in the center of the group with a lowered bullhorn in his hand, deep in conversation with a woman who appeared to be taking notes. That woman was me. As a reporter for the Boston Globe, I was covering the APA's annual meeting in Montreal that year. I too had noticed the demonstration and had gone over to investigate.

  Teicher immediately recognized who the noisemakers were: Scientologists. The Church of Scientology had been founded in 1953 by a science fiction writer named L. Ron Hubbard, who had written books attacking psychiatry as the dark art. Hubbard was now deceased, but in the past few months, Scientologists had taken up the supposed ills of Prozac as part of their campaign to discredit psychiatry.

  Teicher knew that Prozac had disturbing side effects in some patients. He and his colleagues had observed the drug triggering persistent, obsessive, and violent suicidal thoughts in the six patients in their case report. He also knew that Prozac had a particularly long-lasting effect on the body's metabolism and that many patients harbored selfdestructive urges even after they stopped taking the drug. Two weeks after Teicher took Ms. D. off Prozac, she attempted to kill herself, consuming a lethal combination of Valium and alcohol, and this time she would have succeeded had her sister not discovered her and rushed her to a nearby hospital. Even so, Teicher and his coauthors suspected that these suicidal behaviors occurred only in a small subset of people on Prozac. For his case report, Teicher had totaled up all 170 patients that he and Cole had treated with Prozac as outpatients and estimated that suicidal ideation occurred in perhaps 3.5 percent of them. It was a very rough estimate, he realized, but whatever the real percentage of people who developed suicidal thoughts on Prozac was, it certainly didn't constitute a majority of those treated with the drug.

  The McLean researchers had made it clear that their purpose in publishing the case study was to bring this occasional phenomenon to the attention of doctors and patients so that they could be on the lookout for its emergence during the first weeks of treatment. None of Teicher's own patients had responded well to Prozac, but according to anecdotal reports from his colleagues, the drug really did help many patients, particularly those whose chronic depression had not res
ponded to other antidepressants. He himself intended to keep prescribing Prozac when he felt it was warranted. He wanted nothing to do with an extremist group whose mission was to destroy the very credibility of his profession. He walked away.

  LATER THAT EVENING, Teicher joined a few colleagues for dinner at the Bistro a Champlain, an expensive French restaurant in Montreal with an Old World flavor. With its wainscoted walls and the rich cigar smoke wafting through the air, the restaurant reminded him of a private men's club. Teicher was seated next to Bruce Cohen, a wellregarded psychiatrist who would later become the president of McLean Hospital. Also at the table were Carol Glod, Teicher's coauthor, and George Zubenko, a psychiatrist and an old friend who had trained with Teicher at McLean and would soon take an appointment at the University of Pittsburgh. As Teicher savored his dessert, he became aware that a group of men at the next table were chattering excitedly about the buzz surrounding their new drug and the rave reviews it had received at the APA conference that day. They were sales representatives from Eli Lilly, the maker of Prozac, Marty realized, and they were raising their drinks in a toast. One of the men stood up and said, "To Prozac! May its side-effect profile never change!"

  As he watched the men laugh and clink their glasses in unison, Teicher leaned over to Cohen, who had also noticed them. Thinking of the case study already accepted for publication, he whispered, "I'm afraid it's going to change." Only later would Teicher realize just how prescient his off-the-cuff comment had been. Lilly's fight to make Prozac a blockbuster drug would haunt Teicher's own life in ways the ambitious young psychiatrist couldn't begin to imagine.

  leary-eyed, Rose Firestein looked up from her computer screen and the messy sheaf of papers on her desk. It was after 1 a.m. and she'd been working for close to sixteen hours on a brief for the Legal Aid Society of New York. At this hour, there was no one else in Legal Aid's cramped offices on Park Row in Lower Manhattan. Even the cleaning women had come and gone. The place was silent and shadowy, but Firestein didn't mind. This was when she got her best work done. A few years back, she had pulled an all-nighter while preparing the initial filing for a mammoth lawsuit against New York City's Social Services Department. On the way home the next morning, she'd fallen asleep on the F line and missed her stop in Queens. She wasn't going to let that happen again, Firestein vowed as she rode the elevator down from the twenty-first floor. This time, she'd find a cab. Hopefully.

  When Firestein first joined Legal Aid, some of her new colleagues hadn't taken her seriously. Rose Firestein didn't look particularly formidable. She stood all of five feet one inch in her stocking feet and had silky, white blond locks and hazel eyes. This wasn't the first time others had underestimated her, and it would not be the last. In her second job out of law school for the Indiana Center on Law and PovertyFirestein had been working on a race discrimination case on behalf of several young black men who were hired part-time for below-normal wages at a small manufacturing plant in Elkhart, Indiana. After months of dickering back and forth, the middle-aged attorney for the manufacturing company told Firestein to craft a draft proposal for a possible settlement and he'd see what he could do. A few days after she turned in her proposal, a treatise that ran to many pages, the company attorney called her up and said admiringly, "Rose, you've been hiding your light under a bushel!" In the settlement, not only did Firestein's clients receive back pay, but the company hired them full-time and put in place its first-ever affirmative action plan.

  After her stint in Indiana, Firestein moved to Savannah, where she worked as a senior staff attorney for the Legal Services of Georgia. There, she and several colleagues sued the Tattnall County Board of Education, accusing county officials of resegregating Tattnall's schools in the way they tracked and separated black and white students. "They assigned black kids with borderline IQs to classes for mental retardation while the white kids with the same measured IQ were assigned to specific learning disability classes," Firestein said. She and her compatriots won that case and went on to sue the Georgia State Department of Education and twelve counties for the same discriminatory practices. The statewide lawsuit stirred up a hornet's nest. An attorney representing one of the school systems, an elderly man from a white-shoe law firm, told her, "You're trying to ruin my way of life!"

  Rose Firestein had not set out in life with that goal in mind; it just wasn't her nature to back down in the face of resistance. She was stiff-necked that way, just like her father, a Jewish grocer's son who had pulled himself up out of poverty to become a respected cardiologist in South Bend, Indiana. Her father had raised all four of his children-three girls and one boy-to be independent adults who could make their own way in the world. Rose's older sister, Janice, was an information technology manager for Merrill Lynch in New York City; her brother, a corporate consultant. Her younger sister worked as a para legal in a law firm. Rose herself was a workaholic, pale from spending so much time indoors. At the office, she was known for being among the first to arrive and last to leave. One time, her boss, only half-joking, told a visitor, "Thank goodness Rose works twenty-four hours a day."

  With her glasses and small stature, Firestein was not the kind of woman who automatically drew a second look. At the office, she dressed conservatively, in a tailored skirt or pants suit and shell top. So co-workers who didn't know her well were caught by surprise when she opened her mouth. Firestein had a salty way of expressing herself. When something wasn't going well, she could be heard to mutter an "Oh, hell." One time when a colleague asked her how she had unearthed a document that turned out to be crucial to their legal case, Firestein responded, "A little song, a little dance, a little something in your pants." Her associates sometimes couldn't believe the things that came out of Rose Firestein's mouth. But she made them laugh-that was the important part.

  Firestein had never been shy about expressing herself. It came from being the third child in a big family: you had to make noise to get noticed. She was also quick to rise to the defense of the injured party when she perceived an injustice-sometimes too quick. Once, when she was just starting out as an attorney, working for the Indiana Civil Rights Commission, she and her boss, the executive director of the commission and the only African American in an executive position in state government, had looked around and observed that blacks were significantly underrepresented in the state's workforce. They decided to do something about it, so they served an extensive subpoena on the State of Indiana's Department of Personnel, seeking records that would document the situation.

  A few days later, they were called in to see the then governor of Indiana, Otis R. Bowen, who very politely said he understood their concern about diversity. However, this was not the way to go about things. After the pair left Bowen's office, they were pulled aside by one of his aides, who was not so polite. The aide lambasted them for not going through the proper channels. What Firestein remembered most vividly, though-the memory that stayed with her some thirty years later-was that excruciatingly long walk across a large blue rug to reach Governor Bowen's desk. Every step had seemed an eternity.

  Over the years, Firestein learned how to curb some of her Don Quixote tendencies. By the time she began working for Legal Aid of New York in 1984, she was a seasoned litigator who understood the value of thinking things through. In less than a year with Legal Aid, she was named lead attorney on one of its biggest class action suits ever, Doe v. New York City Department of Social Services. It was at the height of the crack epidemic, and many of the children removed from their homes were being kept overnight in the department's field offices and moved on a nightly basis from one office to the next. There were simply not enough home placements for all the neglected and abused children flooding the foster care system. Legal Aid's lawsuit was an attempt to force the city to provide the resources necessary to get these foster children into decent long-term placements.

  What Firestein saw while collecting evidence for the Doe lawsuit made her want to go out and hurt someone, bad. During visits to the DS
S field offices, she observed the empty eyes of foster children kept overnight with no place to go. She smelled the tangy odor of their unwashed bodies. But what horrified her even more were the stories she gleaned from family court files of children who had been put on potent psychoactive medications-drugs designed to alter the very chemistry of the brain-with no one to monitor their condition or watch for the drugs' often dangerous side effects. One child, who had been removed from his home after being abused by his mother and remanded to his father's custody, ended up in foster care at the age of twelve when his father died of an overdose. "Victor" had been placed at the St. Christopher's group home, but the facility had kicked him out after a month, claiming he was "disturbed and uncontrollable." At that point, Victor had been put on Haldol, a powerful antipsychotic drug, and transferred from one DSS facility to another, often staying somewhere only a single night before being moved again. By the time a court-appointed psychiatrist caught up to his case, Victor was beginning to suffer from involuntary muscle tics, a common side effect of Haldol.

  Rose Firestein was not a squeamish person. Having accompanied her doctor father on occasional house calls and worked as a nurse's aide in a South Bend hospital, she had seen her share of sickness and death. She cherished the memories of driving to house calls with her father; they were among the only times she had had him to herself. She had even toyed with the idea of following her father into medicine. Of all her siblings, Firestein most resembled her father, a brilliant man who was passionate about medicine but had many other interests: woodworking, gardening, reading. Firestein too was fascinated by the medical sciences. But as a child growing up in the nation's heartland, she had heard President Kennedy's call to make the world a better place. Social justice became her passion, and Rose Firestein decided that the law would provide her with a better means than medicine of pursuing that cause.