The "Side Effects" of Big Pharma as Examined by Hollywood

[Warning: The following article contains major spoilers of the film Side Effects. If you have not seen the film and do not wish to have key plot points (including the ending) revealed, do not read further.]

In the last two decades, enormous shifts have occurred in health care, but few (if any) have had the economic or social impact of the proliferation of psychiatric drugs. According to the American Psychological Association, the rate of adults in the United States who use psychiatric drugs rose 22% between 2001 and 2010, with one in five adults now taking psychiatric medication. Concern over this trend has led to the rise of anti-psychiatry movements and has been stoked by repeated allegations of corruption against high profile pharmaceutical companies.  In fact, the pharmaceutical industry has become one of the least trusted industries in America, which is reflected by its portrayal in the popular media. In particular, Oscar-winning films like The Fugitive and The Constant Gardener have villainized the industry in memorable and powerful ways. This trend remains strong with perhaps the most direct indictment of the pharmaceutical industry yet slipping into theaters with little fanfare earlier this year.

Side Effects, which was released in February 2013, is set up as a thriller with a controversy regarding a psychiatric drug at its center. The film follows a young woman named Emily Taylor who has a long history of severe depression that has responded poorly to medication. Her symptoms flare up shortly after her husband is released from a four-year prison sentence for insider trading. She makes an impulsive suicide attempt and ends up in the care of a well-meaning psychiatrist, Dr. Jonathan Banks. He prescribes her Ablixa, a new antidepressant undergoing a clinical trial that he recently agreed to work on (for a substantial paycheck). The titular side effects of the drug shortly kick in and she ends up stabbing her husband to death while sleepwalking one night. As one would imagine, the story becomes a media circus and blame is quickly shifted to Dr. Banks for prescribing the medication. On the verge of being publicly disgraced, Dr. Banks goes out to clear his name and soon realizes that all is not as it appears to be after looking into Emily’s former psychiatrist, Dr. Victoria Siebert.

At this point in the film, many of the most potent controversies facing the pharmaceutical industry have been intriguingly dramatized. Was it in fact the side effects of the antidepressant medication that caused her to kill her husband? If so, how did the drug get to this phase in the clinical trials without this side effect being detected? If the drug is at fault, then who is primarily responsible – the pharmaceutical company that manufactured it or the psychiatrist who prescribed it?

It is important to dispel two common myths as readers start pondering these questions. The first is the argument from the anti-psychiatry zealots that psychiatric drugs do more harm than good. Countless studies have shown that psychiatric medications are not only safe and effective, but actually the first-line treatment for several disorders, including schizophrenia, bipolar disorder, and Attention Deficit Hyperactivity Disorder (ADHD). These medications are not successful at reducing every afflicted patient’s symptoms and some individuals experience aversive side effects, but on the whole they do more to benefit patients than damage them. They are not the only option, however. Psychotherapy is still the first-line treatment for many disorders, including many anxiety disorders and personality disorders (among others) and even in cases where medication is the first-line treatment, psychotherapy is almost always still beneficial, even if it is primarily a supportive therapy aimed at helping the individual manage their residual symptoms, adhere to their medication regimen, and handle environmental stressors that may cause symptoms to recur or worsen. Of course, there remains a large contingent of psychiatrists and psychologists who hold steadfast that their particular brand of intervention can solve all of their patients’ problems, but thankfully the two professions are increasingly acknowledging what the other has to offer in terms of alleviating suffering due to mental illness.

The second myth that needs to be dispelled is that pharmaceutical companies are a purely greedy enterprise that serves no real purpose other than to make money and that any doctor that “gets into bed” with them is of questionable morality. Ultimately, these companies are the sole financial backers of any research involving psychiatric drugs. It is extremely difficult to find a government agency or independent funding source that is willing to fund research that involves the evaluation of the safety and efficacy of a psychiatric medication. The doctors who “get into bed” with these companies are often subjected to great scrutiny and suspicion, but the vast majority of them are just good doctors who want to be involved in research regarding treatment for mental illness. Dr. Banks appears to be one of these good doctors at this point in the film. Although his responses to Emily’s refusal to be admitted to the hospital following the suicide attempt and her inappropriately tracking him down when he is unavailable to take her phone calls may not be great case studies for ethics classes, they are well-reasoned and well-intentioned. He takes appropriate caution when the pharmaceutical companies approach him to participate in the trial and provides fully informed consent when suggesting the medications to his patients. He presents a genuine interest in Emily, shows her genuine positive regard, and even contacts her previous provider to gather more information about her.

Both for better and worse, the film’s second half takes an unpredictable turn. Dr. Banks’ investigation leads him to the conclusion that Emily is faking, well, everything. It turns out that Dr. Siebert and Emily had become lovers and hatched a scheme to have Emily convincingly fake her seemingly severe mood disorder, convince her doctor to put her on a particular drug, and fake tragic side effects. Why go to these lengths? Money, of course. The pair used Emily’s vast knowledge of insider trading to invest large sums of money in the pharmaceutical company that manufactures the primary competitor to Ablixa (the drug Emily was on at the time of the murder). The stock for this company naturally soared while the press painted Ablixa as a drug that just might lead you to kill your spouse in your sleep. (Please note that I am purposefully ignoring the strange lesbians-as-villains plot twist; that is another issue for another day.)

Is this twist salacious? Definitely. Is it ridiculous? Sure. But after all this is Hollywood, and perhaps expecting a more realistic end to this film was wishful thinking. However, the titillating direction the plot diverges in still raises several fascinating and vital questions about the field of psychiatry. One is the “myth of mental illness” debate, most notably espoused in the 1960 book by the late psychiatrist Thomas Szasz. His general assertion is that because no objective medical tests exist that can reliably confirm or falsify the presence of mental illness, such a diagnosis is merely an unsubstantiated moral judgment. Although there are problematic theoretical grounds for his argument (e.g., there are a number of well-established medical illnesses that are diagnosed by deduction and not by the result of a single definitive test), it does raise the very real issue that psychiatric illnesses are much easier to fake than medical illnesses. Such faking is termed “malingering” and is done for a wide variety of reasons, such as a criminal trying to be declared not guilty by reason of insanity, a person wanting to continue receiving their disability payments, and – I suppose – even people who want to make millions off of insider trading. However, just because individuals can fake the symptoms and we do not have an objective test (yet) that can confirm or deny the true presence of the disorder does not mean that the disorders themselves do not exist. A simple visit to a local community psychology clinic makes it hard to deny that mental illness is very real.

The film’s rather strange turn also highlights the interesting multiple meanings of the film’s title. The most literal interpretation is that the title refers to the side effects of Ablixa that Emily was faking, which sets the whole plot into motion. One could also interpret the title as referring to the side effects of working with an industry with obscene amounts of profit and power, which can easily lead to corruption.  Furthermore, the title could refer to the side effects of working with the mentally ill. Although it is far less common than cinematic thrillers, police procedurals, and crime novels would have you believe, there is a fair amount of malingering and manipulation when working with people with mental illness, as exemplified by various unsubstantiated allegations made by former patients against Dr. Banks in the film and the actions of Emily (who may not have a mood disorder but clearly has some psychological issues).

Of course, by the film’s second half, any positive portrayal of psychiatry has been all but decimated. Dr. Siebert is the very embodiment of the unethical psychiatrist, taking advantage of patients and manipulating the system for financial gain. Even Dr. Banks goes down a nasty spiral of revenge that results in countless ethical violations. In general, the film does a somewhat noble job of acknowledging that these are in fact serious ethical violations that have dire consequences. (At least this is true until the film’s final scene; see below). Still, the film troublingly promotes fear of psychiatry to viewers by raising the possibility of deadly side effects from antidepressants and dramatizing abysmal behavior on the part of mental health professionals. In a society in which an ill-informed mistrust of psychiatric medications prevents countless individuals from initiating treatment that would likely improve their quality of life, such fear mongering is highly problematic.

Although it was generally well received by critics, the film did not reach a particularly wide audience, underperforming at the domestic box office where it just barely recouped its $30 million budget. This is not surprising when you consider the release date (February is typically a time for studios to dump mediocre films), lack of promotion, and its unflashy execution. The film did, however, come with an impressive roster of talent both on- and off-screen. The film was written and produced by Scott Z. Burns, the man behind the Oscar-winning climate change documentary An Inconvenient Truth and the megahit spy thriller The Bourne Ultimatum, and directed by Hollywood heavy hitter Steven Soderbergh. After bursting into Hollywood with the crossover success of his racy independent drama sex, lies, and videotape in 1989, he spent nearly a decade making quirky films that underperformed critically and commercially. In 1998, he rebounded with a series of high profile well received films, including Out of Sight,The Limey, and the Oscar-winning megahits Erin Brockovich and Traffic, which brought industrial pollution and the war on drugs to life in massively entertaining and thought-provoking ways. In the past decade, his output has been high but successes have been infrequent. He has a few big hits (Ocean’s Eleven, Twelve, and Thirteen; Magic Mike) but mostly a host of more experimental films that were tepidly received (Solaris, The Girlfriend Experience, Che, Haywire, etc.)

He does a nice job with Side Effects despite its somewhat problematic script. He creates a rich atmosphere, establishes a swift pace, and keeps things from playing out too sensationally. He also manages to elicit subdued and nuanced performances from the impressive cast, which includes Jude Law (Cold Mountain, Sherlock Holmes), Rooney Mara (The Social Network, The Girl with the Dragon Tattoo), Catherine Zeta-Jones (Traffic, Chicago), and Channing Tatum (21 Jump Street, Magic Mike). Soderbergh has long been known as an actor’s director, having elicited career-best performances from actors such as Jennifer Lopez (Out of Sight), Julia Roberts (Erin Brockovich), and Benicio Del Toro (Traffic).

Where Burns and Soderbergh stumble a bit is at the very end of the film. Dr. Banks successfully gets revenge on Emily and Dr. Siebert and is reunited with his family. He is seemingly unpunished for his second act sins and the film ends on a triumphant note. As the two did with Contagion (their critically and commercially successful 2011 ensemble drama about the outbreak of a pandemic), Burns and Soderbergh seem oddly compelled to make a happy and tidy ending out of dark and complicated subject matter that would have been better served by something more morally ambiguous or even a twist that served a bold sucker punch to the viewer.

As a film about mental illness and its treatment, Side Effects is chocked full of fascinating questions, but answers most of them either poorly or not at all. But at least the questions are being asked and (hopefully) evoking meaningful debate amongst those that take the opportunity to see it.

Psychology in Film Series

This is the seventh entry in Richard's series on the portrayal of psychology in film. The others can be found at the following links:

1) http://www.psychologyinaction.org/2013/01/26/silver-linings-playbook-makes-a-hit-film-out-of-a-risky-concept-a-romantic-comedy-about-the-mentally-ill/

2) http://www.psychologyinaction.org/2012/10/10/shame-makes-a-compelling-case-for-the-legitimacy-of-sex-addiction-as-psychopathology/

3) http://www.psychologyinaction.org/2012/06/22/a-dangerous-method-film-tells-the-story-of-the-rise-of-a-controversial-practice/

4) http://www.psychologyinaction.org/2012/03/28/recent-film-provides-insight-into-the-terror-and-complexity-of-prodromal-schizophrenia/

5) http://www.psychologyinaction.org/2011/12/12/hauntingly-accurate-portrayals-of-severe-mental-illness-at-a-theater-near-you/

6) http://www.psychologyinaction.org/2011/10/24/new-movie-portrays-cancer-perceptively-but-psychology-offensively/