Was Ledger on Too Many Meds?

In the two weeks since Heath Ledger's body was discovered Jan. 22 in his downtown Manhattan apartment, rumors about the cause of his death have swirled. Was it suicide? Illegal drugs? Initial reports were inconclusive. But after conducting toxicological tests, the New York City medical examiner's office concluded Wednesday that the 28-year-old Australian-born actor and star of "Brokeback Mountain" died from an accidental but lethal combination of prescription medications used to treat anxiety, insomnia and pain. They include: oxycodone (the active ingredient in the prescription painkiller Oxycontin), hydrocodone (often combined with acetaminophen for pain relief in drugs like Vicodin), diazepam (an anti-anxiety medicine sold under the brand name Valium), alprazolam (another anti-anxiety drug sold under the commercial name Xanax), temazepam (or Restoril, which is commonly prescribed as a sleep aid) and doxylamine (an antihistamine that can be found in over-the-counter brands like Unisom, which is used for the short-term treatment of insomnia).

The report didn't note what concentration of each drug Ledger had in his body, but it raises unsettling questions. Why did the actor have so many prescription drugs in his possession? And was he properly informed of the potentially deadly result of combining the drugs or ingesting more than the prescribed amount at one time? NEWSWEEK's Jennifer Barrett posed those questions to Charles Barber, a lecturer in psychiatry at the Yale University School of Medicine whose new book, "Comfortably Numb: How Psychiatry is Medicating a Nation" (Pantheon), was published this week. Excerpts:

NEWSWEEK: The coroner's report found that Ledger died from a lethal combination of prescription drugs. Is it surprising that he had so many prescription drugs on hand? 
Charles Barber: I don't want to comment on his case in particular, but I'd say that, in general, it's fairly easy to get prescription drugs from doctors, and people can go to multiple doctors--and the doctors don't necessarily talk to one another.

Why is that?
Psychiatric drugs used to be largely prescribed just by psychiatrists, and what's happened in the '90s and in this decade is that they are now prescribed by primary-care providers--in fact, the majority of antidepressants are being prescribed by primary-care providers [PCPs]. And there can be a real lack of follow-up after they are prescribed. Before the drugs became so widespread, people usually had a therapist involved in addition to drug treatment. Now it's far more common to have drug treatment alone and no therapy and, furthermore, to have a real lack of follow-up around the medications.

In your book, you argue that Americans are being overmedicated, at least for mental-health issues. Why?
The critical sea change came in the mid-'90s when prescription drugs were advertised on TV for first time. The TV commercials for drugs are banned everywhere in the world except the United States and New Zealand. The commercials really turned these drugs into household names, and they [became associated with] commodities like toothpaste or automobiles. But the fact is, they aren't just products. They are powerful agents. Yet studies have shown that in many instances doctors will prescribe drugs that their patients ask for after seeing them on TV, despite feeling ambivalent about the appropriateness of the drug.

Do you find that there is a lack of awareness among consumers about the risks of different medications--even some that seem benign?
That comes from this idea that they are on the TV with Colgate and Chevrolet and Diet Coke. It instills in consumers the idea that they are commodities like any other. The commoditization of drugs has created a sort of entitlement among patients, too. They think, if this drug is doing great things for people on TV, why shouldn't I have it?

Why hasn't there been more of a backlash, or concerns raised, among doctors that this might lead to overmedication or improper medication of patients?
I think that is starting to happen. But doctors are under pressure. Managed care came along at the same time [as the ads], and they are under pressure to process a lot of patients each day. It's easier to write a prescription and send patients on their way. And it's tricky referring people for proper mental-health treatment. Cognitive behavioral therapy can be very effective for mild to moderate depression, but psychotherapists aren't very good at marketing themselves. A busy PCP is not likely to know offhand an appropriate psychotherapist. Prescribing the drug can be the path of least resistance. But the critical issue with the Ledger case, and others, is follow-up.

Are there other lessons we can draw from Ledger's tragic death?
I would just say that when multiple drugs are involved, the interactions and full clinical picture need to be closely monitored by a single person, and it should be an expert in that area--a psychiatrist, for example, when psychiatric drugs are involved. And, in addition, to the ongoing follow-up, they should also be looking at the underlying issues. I doubt that Heath Ledger was seeing a therapist, but clearly he had sleep and anxiety problems. Most people taking those drugs are not seeing a therapist; they are taking the drugs in isolation. So even though the drugs can be effective, the patients are not addressing the underlying issues.

Why don't more doctors prescribe therapy?
For patients, it's hard work and it's painful and time consuming. It's logistically a lot more difficult than going to a pharmacy and picking up a prescription. There are homework assignments. You often keep a journal. It's work, and it's not fun. The other piece is that insurance companies have favored drug treatment over referrals for therapy. And [the therapy] involves looking at things in a more complex way. Change is a complex, protracted process [and our] culture is impatient with that. We like to get the quick fix and be on our way.