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Book Review   |    
Bruce Hurter
Psychiatric Services 2007; doi:
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by Greg Critser; New York, Houghton Mifflin, 2005, 320 pages, $24.95

Dr. Hurter is assistant professor at University of Massachusetts Medical Center, Worcester.

In Generation Rx, Greg Critser reviews changes in the pharmaceutical industry, changes in Americans' relationship to their medicines, and even changes in the concept of illness—defining illnesses by the medicines that treat them.

Critser reviews changes in the drug industry that have had both benefits and significant costs for consumers. He suggests that congressional acts by Evan Bayh and Elizabeth Dole and Orrin Hatch and Henry Waxman, as well as changes in Food and Drug Association funding and mission, have allowed for much greater numbers of drug approvals and shorter renewal times. He asserts that although many of these newly approved medications were important for treatment of AIDS, cancer, and heart disease, most of the approved medications are for treatment of less serious chronic illnesses. He states that pharmaceutical companies have created a paradigm change from "treating disease to creating a state of health." A marked increase in marketing, particularly direct-to-consumer advertising, has expanded the use of medications—often to off-label uses. Medications are simply "marketed as if they were any other consumer product."

He asserts that pharmaceutical marketing has dramatically expanded medication sales by aiming at three "tribes." One tribe is that of "high performance youth." He argues that medication treatments for attention-deficit hyperactivity disorder (ADHD) of youths are overprescribed in part because of marketing. In fact, he argues that a response to stimulants essentially defines the diagnosis of ADHD. He states that another tribe, of people in their midlife, dodges the body blows of increased cholesterol, high blood pressure, diabetes, and depression. However, he asserts the tribe's focus is to continue to manage the demands of performance and productivity with the help of, for example, sleep and wakefulness medications. Last, the tribe of super seniors focuses on a number of diseases associated with aging, such as Alzheimer's disease, diabetes, and depression. Notably, 75% of those over 65 are on daily medications, and polypharmacy is the norm.

Critser emphasizes that it is important to look at the full cost of medications, including economic factors, the risks to our bodies, and the price of the strain on patient-physician independence. He asserts that we are treating chronic conditions with medications for which we usually don't know the long-term consequences, as has been evident in the problems with Vioxx and Zyprexa. Perhaps the greatest cost to physicians is that if we accept these paradigm changes, we risk damage to the traditional patient-physician relationship.

Recently there have been a number of excellent books criticizing changes in health care's relationship to the pharmaceutical industry, but Crister presents an additional perspective. He states that pharmaceutical companies use "new media freedoms to create chronic disease awareness, use political and regulatory power to speed the approval process, use technology to stimulate demand by stimulating patients and doctors, and then use patient information and marketing to make the patient a partner in a lifelong relationship." The explanation of this paradigm shift is well drawn, as are his questions about the costs of long-term treatments. He appropriately shows that the treatment of chronic illness serves the need of pharmaceutical companies; however, it is not yet clear that the benefits outweigh the long-term risks. His review of the cost of advertising, particularly direct-to-consumer advertising, raises particularly disturbing questions about patient-physician relationships. The questions raised are important. I recommend this book for consumers as well as physicians and health professionals.

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