Baby Boomers Leaders in Prescription Overdoses

Baby boomer are accidentally killing themselves with overdoses of prescription painkillers, anti-anxiety and sleep medication at a faster rate than any other group. According to an article in the Wall Street Journal’s Health Blog.

This is the fate that befell Batman’s Joker Heath Ledger. The total accidental prescription overdoses were 22770 in 2004 rising 700 percent since 1983. The Associated Press reports that, “The increase deaths was highest among baby boomers, people in their 40s and 50s.”

Perhaps the young are now beginning a new trend with the use of antidepressants.

Read this People Magazine piece on Anna Nicole Smith’s son Pathologist: Meds Killed Daniel Smith.

Canada and Thomas Edison’s Contribution to Depession Treatment

Science Daily reports that the first clinical double-blind study of deep brain stimulation (DBS) for treatment of depression is being conducted by St Jude Hospital. However it’s Canada which has led the way in this form of therapy.

DBS stimulates the brain using electrical current from a device that is implanted near the collar bone and connected to electrical leads to targeted areas of the brain. Mild current is sent to an area of the brain called Broadman 25 which has been previously identified by Canadian researchers as overly active in people suffering major clinical depression.

The Toronto Globe Mail has a story Mending a Broken Mind which interviews Sean Miller a young man who is using the DBS device after years of suffering. There is also lots of information about the procedure; more in-depth coverage of how DBS works; and the people behind making Canada the pioneer in using electrical current to treat depression.

Who knows? Thomas Edison may eclipse designer drugs, gene therapy and Sigmund Freud all together.

Psychiatrist Says, “Depression not a Disease”

National Public Radio devoted its show Science Friday to a debate between a psychiatrist who maintains that depression is not a disease and one who thinks that depression is a medical illness.

The two principals were:

• Harvard trained Dr James Gordon who founded and directs The Center for Mind-Body Medicine in Washington. Dr Gordon is the author of a new book Unstuck which prescribes a holistic program to deal with depression
• and Dr Peter D. Kramer who teaches at psychiatry at Brown University and practices psychiatry in Rhode Island. Dr Kramer is the author of many books including Listening to Prozac and Against Depression. The latter argues that the term depression has many meanings in our culture but most important is the fact that depression is a medical illness.

What is Depression

To Gordon, depression is a signal that something in one’s life is out of balance and can be a beginning to transformational change where a person can become unstuck and move forward.

On the other hand, Kramer sees depression as a cluster of disease traits and symptoms:

• Level of pain;
• Runs in families;
• Disruptions in normal brain activity;
• Co-morbidity with other illnesses such as diabetes and heart disease;
• And tendency to be recurrent and progressive.

So depression looks, smells and acts like a disease to Kramer.

Causes of Depression

Dr Kramer pressed his point that a depressed person’s brain activity and anatomy is abnormal. The head of the Center for Mind-Body Medicine responded that everything in the human body has biological manifestations.

Dr. Gordon believes that the primary response to depression should be a integrated program which includes meditation, relaxation, nutrition and exercise and help for the patient see the world and himself differently. Dr Kramer doesn’t write off these techniques but stresses that depression interferes with the ability to function which impacts careers and relationships and is dangerously associated with strokes, suicide and heart disease.

Depression and Medication

Gordon pointed out that recent antidepressant studies have shown them to be less effective that previously reported. The reason for this, according to Kramer is that the standards of research study have been raised:

• Studies now are based on larger samples of people;
• People are screened more rigorously before they come into to a study;
• And a closer review is conducted on the people who seemed to improve on the drug.

Dr. Kramer also mentioned that the studies of the effectiveness of psychotherapy has shown lesser results recently because the test bar in research studies has been set higher.

Dr Gordon maintains that usually stress is the primary cause of depression and the patient should first be guided through a multidisciplinary program; and that medication is the treatment of last resort for the very small percentage of people don’t respond to holistic treatment.

Morality and Spirit

During one exchange as Dr Gordon was making the point that a person needed to be guided through his program so that the patient could learn to help himself. Dr Kramer reacted by saying that the use of the word “guide” had a moral and spiritual feel to it that made him uncomfortable. Gordon responded by saying that doctors do help to save souls and they have a moral duty to do so. Kramer acknowledged that religion or spirituality can be very important to the patient.

A lot of what Dr Gordon had to say makes sense. In an ideal world, I would agree with his approach. Medications should be the last resort and not the first.

The profession of psychiatry is in a crisis. Efficacy claims for both psychotherapy and medications have been dropping based on new research studies. To be in the position of saying the reason the two treatments looked good a few years ago is due to bad research practices is devastating.

But there are elements of both our culture and the human equation that neither doctor brought up that explains what’s going on:

• Insurance companies have reduced psychiatrists to pill dispensers because it’s cheaper for a patient to spend 15 minutes talking with a doctor who then writes a prescription and sends them out the door. Of course the psychiatrist will prescribe a med, he’s a human being and wants to help is patient.
• Most people don’t have the time, interest or energy to participate in a multidisciplinary holistic program. Dr Gordon has stories in his book about people who have stretched themselves and been successful but they are very much the exception and not the rule. So the idea of taking a pill is probably the most attractive option for people.

Based on what I heard on Science Friday, I understand why we are in the mess that we are in. A healthy life style falls by the wayside when people don’t have the energy or time because they are figuratively running to stay in place economically; it’s difficult to change old habits; and there is big money to be made and time to be saved with drugs,

Antidepressants: No Diagnosis, No Problem

“Forty-three percent of those who had been prescribed antidepressants, had no psychiatric diagnosis or mental health care beyond the prescription of the drug.”

This comes from The Medicated Americans: Antidepressants Prescriptions on the Rise in the February issue of Scientific American.

The statement is mind-boggling. Most of these prescriptions are written by the family doctor for a drug that can have serious, even fatal side effects.

Reasons

I can see four reasons for this.

• Extensive advertising by pharmaceutical companies create such consumer demand that when many people visit their doctor they ask for an antidepressant and the doctor simply complies.
• The insurance companies steer people towards antidepressants because a pill is cheaper and simpler than paying for therapy or encouraging people to live a healthier life style.
• Many people are under tremendous stress.
• Old habits die hard; most people want a magic bullet. Take a pill, no fuss, no muss.

Results

People are taking antidepressants with no valid medical; others are not getting the thorough medical care they need. This results in some people:

• Becoming even more ill because they are receiving only partial treatment;
• Running to their family physician to take a pill for no medical reason instead of dealing with the root cause of a problem or making simple lifestyle changes.

It also results in a huge waste of money.

The pharmaceutical and insurance companies get richer, lots of money is wasted and people get sicker.

Should Your Child Take Prozac? Ask the Grocer

An article in the The Australian highlights the ambivalence of modern societies towards psychotropic drugs. Particularly the use of those drugs to treat children.

Consider the difference between label warnings in Australia and the US.

• United States – “On the packet of one leading brand, the following warning is displayed in bold type: ‘Anti-depressants increase the risk of suicidal thinking and behaviour (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders.’”
• Australia – “They all say SSRIs are not recommended for use in children and adolescents for depression, but few reveal the increased risk of thoughts of suicide or self-harm in this group.”

The piece exposes a policy contradiction within the governments of both countries.

Although some drug labels in the US warn of suicide in children while Australia uses a “dis-recommendation”, government funded health insurance programs help people buy these drugs.

A quote from the paper attempts to explain the Australian government’s contradiction.

• “The health department said the decision to pay rebates but withhold marketing approval for the use of SSRIs in children for treatment of depression was a “sensible balance” between the risk of inappropriate prescription and the risk of leaving the illness untreated.”

We are talking about children here. Both governments are passing the buck.

As Australia’s Pharmaceutical Benefits Advisory Committee puts it “These treating doctors will, of course, have to carefully consider the options, risks and benefits of prescribing these medicines.”

Here in the US, Food Drug Administration makes its non-decision about the safety of antidepressants based on information provided by the drug companies; and with a child’s life in the balance, lets the psychiatrist roll the dice.

This is like saying “There’s a tomato salmonella outbreak across the country but we’ll let your grocer decide whether or not the tomatoes you buy are safe.”

Mental Illness: The Courts, Doctor’s Office and Coffee Shop

A June ruling by the Supreme Court is the latest example of our institutions wrestling with the mentally ill’s place in society. Different perceptions about what is right are sometimes based along political and philosophical lines but on the street it’s a different story.

Both the Supreme Court and psychiatric community are struggling with the competence of the severely mentally ill to make their own choices.

The issues at the center of the conflict are the:

• individual rights of the severely mentally ill to make their own choices
• government’s right to protect its citizens
• obligations of health care to serve their patients.

In a split decision, the Supreme ruled that a severely mentally ill person may be competent enough to stand trial with the aid of a lawyer but not competent enough to defend himself.

Majority votes were cast by liberal and moderate judges while dissenting votes were cased by conservative jurists.

This issue is discussed by Dr Peter Kramer on his blog “In Practice”; the title of the post is Degrees of Competence: Do Liberals and Conservative Understand Mental Illness Differently?

The liberal majority indicated that they felt a judge could finely grade the competence of a severely mental ill person; and their ability to participate in their own defense. The underlying assumption is that participating in the trial with the aid of a lawyer is less demanding than defending one’s self.

On the other hand, the dissenting votes of conservative Court members seemed to give the absolute concepts of autonomy, liberty and individual rights greater standing. In the case before him, Judge Scalia also cited the coherence presented by the man who was on trial.

Some people who are psychotic can be artful about how they communicate but yet be suffering from severe delusion. Perhaps Judge Scalia was more worried about the protection of the public at large or the courts being co-opted to send people to the gulag than the nuances of justice for the mentally ill.

The psychiatric community also struggles with the patient’s ability to act in his own self interest.

Does it take less competence on the part of a psychotic patient to accept a doctor’s recommendation than to refuse it. Some ethicists says “yes”. Refusing a doctor’s recommendation is a more complex decision because it would require evaluating other options.

A more specific example of this dilemma is whether or not the government can force a person to take their medications

In some states if the People determine that the person is a danger to himself or others, they entitled to force them to take their meds. As a practical matter states don’t have the resources to monitor compliance.

IMO, judges should exercise the ability to understand the level of competence of a person with severe mental illness so they can participate in their own trial to the maximum extent possible; and states should be able to force a patient to take medication for the protection of the public and patient.

As for the competence of a severely ill person to make his own health decisions, the person has every right to make choices as long as he is not dangerous.

In these extreme circumstances, society’s burden to respect the rights of the mentally ill falls upon the psychiatrist and the judge. As for the every life, affirmation and respect for people with mental illness severe or not, can lift the rest of us whether at work, a sporting event, or the neighborhood coffee shop.

Psychotropic Drugs and Children, Buyer Beware

When Ana Bailey was diagnosed with anxeroia at the age of 12, her psychiatrist prescribed an antipsychotic medication which had weight gain as a side effort. Three years later, Risperdal a drug used to treat schizophrenia, has caused another side effect; dystonia, a painful nerve condition in Ana’s back which requires her to awkwardly twist her neck for relief.

Risperdal is not approved for the treatment of eating disorders.

A doctor can prescribe any drug for any condition. This practice is called using a drug “off-label”. The Federal Drug Administration takes a lassiez faire approach; the regulatory agency neither approves nor promotes “off label” use.

The government requires a pharmaceutical company to get approval for the drug’s initial purpose but after that its buyer beware. Drug companies seldom seek approval of a drug’s new “off label” use because of the time and expense.

So a psychiatrist can prescribe a drug for a child even though it’s only approved for adults.

The post Harvard Professors Flunk Appearance of Propriety documents the pervasive influence of drug company money upon the psychiatric promotion and prescription practices. In the end, corporate marketing influences the type of care a patient receives.

Nevertheless, the profession maintains that it’s independent even though they accept payments from drug companies. When questioned about the appearance of impropriety, psychiatrist Dr Susan Albrecht offered this tone deaf response to the NYT “If someone takes the point of view that your doctor can be bought, why would you go to an E.R. with a sick child and say ‘Can you help me.’”

Because your desperate and there’s no alternative?

Dr. Sharfstein, past president of the American Psychiatric Association, comments in the same article about how patent-protected expensive Lexapro is the top selling antidepressant in the country over the generic Prozac,

“Prozac is just as good if not better, and yet we are migrating to the expensive drugs instead of the generics. I think it’s the marketing.”

Marketing by pharmaceuticals and psychiatrists also seems to have had a huge influence on the increased diagnosis of bipolar disorder in children and the rise of “off-label” prescriptions of antipsychotics and antidepressants to them.

The number of kids diagnosed with bipolar has increased 40 times in a 9 year period and evidence is scarce that the antipsychotics and antidepressants even work.

The story of Ana’s anxeroia, lexapro over prozac and the treatment of children for bipolar are like canaries in a coal mine; all suggest that something is terribly wrong with the drug companies, academics, researchers and psychiatrists that makeup the pharama medical complex.

If Ana’s mother can’t trust her daughter’s doctor for the full story, she is forced to do a lot of homework and make decisions about a complex topic for which she has neither the training nor the experience. There has to be a better way.

Depressed Women Say Viva Viagra

A study funded by Pzifer, maker of Viagra, indicates that the drug can be used by women to counter the sexual side effects of antidepressants; which for some, causes a lack of libido or the inability to achieve organism.

The number of women who participated in the trial was extremely small and the results of this research contradicts all previous studies.

The study which compared the results for women using Viagra with those who were given a placebo may have been compromised by the fact that the women in the antidepressant group may have known they were taking the drug used for sexual dysfunction.

Dr. Irwin Goldstein, director of sexual medicine at Alvarado Hospital in San Diego, says he already prescribes Viagra to some of his female patients, “[Y]ou think about men and women, there are a lot of similarities.”

Dr. Glenn D. Braunstein, an endocrinologist and chairman of the department of medicine at Cedars-Sinai Medical Center in Los Angeles talked about the research and its impact on sales,

“This is a provocative study, but I would love to see it confirmed in a larger group of women,” he said.

“If I had to predict, use of Viagra will go up,” he said. “A woman might not even ask her gynecologist for it — she might just ask her significant other to give her some.”

It will be interesting to follow this story and see if larger clinical trials confirm the results of this widely published study.

FDA Reviews Respiratory Drug For Association With Suicide

It’s important to be aware that drugs, other than psychiatric drugs, can have a potential impact on mental health.

The Food and Drug Administration announced a safety review of the asthma drug Singulair (montelukast). It’s looking at the association between the medication; mood changes, suicidality (i.e. ideation) and suicide.

The agency explained that the review was intitiated by inquiries about Singular. The FDA also reports the drug manufacturer Merck & Company has updated its prescribing and patient information several times including “the following post marketing adverse events.”

• Tremor, March 2007
• Depression, April 2007
• Suicidality, October 2007
• Anxiousness, February 2008

The FDA expects the review of Singulair to take about 9 months.

“Feeling Good” May Be Hazardous to Your Heath

The book Feeling Good The New Mood Therapy by David Burns M.D. has released a “revised and updated version” proudly proclaiming more than 3 million copies sold. This book is almost 30 years old and it shows. Based on cognitive behavior therapy, some of the hype and contents can be very damaging to be people with serious depression.

Let’s look at some of its assertions one by one.

1. “The first principle of cognitive therapy is that all your moods are ‘created’ by your “cognitions” or thoughts.”

In otherwords if you are seriously depressed, it’s all in your head. So it must be your fault, right? There is tons of scientific research that say otherwise; genetic vulnerability passed down from generation to generation; chemical imbalance, over activity in regions of the brain and distortions in its anatomy.

There is not doubt that distorted thinking, “cognitions”, play a significant role in depression; and that Dr Burns book shows a person how unconscious assumptions undermine wellbeing but to suggest that a person, with serious problems with the biology of their brain, can treat themselves is irresponsible.

The book sets up people suffering with depression for failure which is absolutely the last thing they need.

2. 70% of the depressed individuals who read Feeling Good improved in four weeks even though they received no other treatment.

Depression is a chronic potentially progressive disease which requires serious medical intervention. A patient using multiple methods to fight back is much better off. Medication, therapy, exercise and meditation can used in different combinations.

3. If depression is inherited doesn’t it mean we should treat it with drugs… not necessarily.

I agree the phrase “not necessarily” is the appropriate response however Dr Burns goes on with an silly, if not dangerous, analogy.

“We all inherit … a particular body type…Many professional bodybuilders were skinny and embarrassed about their looks when growing up. This motivated them to go to the gym and work out . This intense effort transformed many of them into champions”.

Say what? What does this have to do with a medical illness. The purpose of these statements is to continue the drumbeat of “It’s all in your head. If you are motivated and do the work, you do it yourself.

Some of the most ridiculous hype comes on the very first page.

4). “Feel Good Feels Wonderful You Owe It to Yourself to Feel Good!,’I would personally evaluate David Burns Feeling Good as one of the most significant to come out the last third of the Twentieth Century’ – Dr. David F. Mass, Professor of English, Ambassador University’

Professor Mass should stick to Shakespeare.

This book provides some helpful information about antidepressants; but the bottom line is the premise and rhetoric of Feeling Good exploits the “do it yourself” mentality of many people and contributes to the shame that some people feel about their condition and reluctance to seek medical treatment.