Ben Goldacre might be quite surprised to hear he’s written a sociology book, but for the second in our series on books about how the science of mind, brain and mental health meet society, Bad Pharma is an exemplary example.
The book could essentially be read as a compelling textbook on clinical trial methodology with better jokes, but the crux of the book is not really the methods of testing medical interventions, but how these methods are used and abused for financial ends and what impact this has on professional medicine and, ultimately, our health.
In other words, the book looks at how clinical science is used socially and how social influences affect clinical science.
For example, this is question I often give students: If a trial is badly designed, are the results more likely to suggest the treatment is effective or more likely to suggest the treatment is ineffective?
Most students, naive to the ways of the scientific world, tend to say that badly designed trials would be less likely to show the treatment works but in the real world, badly designed trials are much more likely to give positive results.
There is nothing in the science that makes this happen. This is an entirely social effect. It’s worth saying that that this is rarely due to outright fraud but it’s those little decisions that add up over time, each of which seems completely justifiable to the researcher, that sway the results.
It’s like if your dad was school football coach. You’d probably get picked for the team more often not because your father was making a conscious decision to include you no matter what, but because he would genuinely believe he had recognised talent where others probably wouldn’t.
For scientists, the treatment they are testing is often their ‘baby’, and the same sort of soft biases creep in between the cracks. And the more cracks there are, the more creep occurs.
On the other hand, pharmaceutical companies are often deliberately trying to promote their product by distorting the evidence for its effectiveness. This often happens within the accepted regulations – the unethical but legal realm – but happens surprisingly often outside the law.
Bad Pharma is not specifically about psychiatry but as one of the medical specialities which is most corrupted by the influence of large pharmaceutical companies, it turns up a lot.
It is both an essential guide to understanding how treatments for mental health conditions are tested and has plenty of examples of how psychiatric drugs have been the subject of spin, over-selling and fraud.
Perhaps the only part where I think Goldacre is being too strong is in his criticism of ‘me too drugs’ which are new drugs which are often molecularly similar but no more effective for the target symptoms than the old ones.
At least in psychiatry, one of the big problems is not so much the effectiveness of the drugs, but their side-effects. Having other compounds which although no more effective may be more agreeable or less risky is a genuine benefit.
Goldacre is clear about this being a benefit, but I think he under-values it at times, especially since a lot of mind and brain medicine involves iterating through medications until the patient is happy with the balance between effectiveness and side-effects.
But this is a small point in an excellent book. It is essential if you want to know how medicine works and doubly essential if you have an interest in the mind, brain and mental health where these issues are both a significant battle ground and often under-appreciated.
I suspect Goldacre would prefer to call the book political rather than sociological, but if you are studying psychology, neuroscience or mental health it is a must read to understand how clinical science meets society.
Next and finally in this three-part Mind Hacks series on science and society – Didier Fassin and Richard Rechtman’s The Empire of Trauma.
Link to more details of Bad Pharma.