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Seductive Solutions for Rough Illnesses
November 8, 2005 7:43 PM   Subscribe

Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature
posted by daksya (60 comments total) 3 users marked this as a favorite

 
That is interesting. I wonder if it will filter into the mainstream. The FDA has certainly been getting its knock over the past few years.
posted by edgeways at 8:04 PM on November 8, 2005


Interesting article. Sort of. It is always puzzling and somewhat sad when someone steps in with a piece of "research" (this is effectively a meta-analysis) that doesn't really advance science, doesn't improve patient care, and ultimately leaves patients with severe illnesses further marginalized when said article gets reduced to a ten word sound-bite on the evening news. Anyone that treats depression, and anyone who has benefitted from an antidepressant, will attest to their efficacy. It's doubtful they lose much sleep wondering why.

DTCA is a total load of shit, though.
posted by docpops at 8:05 PM on November 8, 2005


For instance, sertraline (Zoloft) was the sixth best-selling medication in the US in 2004, with over $3 billion in sales [2] likely due, at least in part, to the widely disseminated advertising campaign starring Zoloft's miserably depressed ovoid creature.
I love an abstract with a sense of humor.
posted by blendor at 8:07 PM on November 8, 2005


Here's an article in PDF about the serotonin hypothesis itself in Nature Reviews Neuroscience.
posted by Gyan at 8:13 PM on November 8, 2005


I love an abstract with a sense of humor.

PLoS isn't one of the journals my team of proofreaders works on, but it *is* on the other team, and the guy who works on it regularly brings over extremely fascinating articles.

Many of them have humor in them, such as one that went to press (!) with the phrase "[...] what we basically did was collect a shitload of bull semen [...]".

PLoS is awesome. I wish I got to work on it.
posted by interrobang at 8:15 PM on November 8, 2005


docpops: The authors do address that, at least somewhat... it seems to me they're more arguing against the theory of low levels of serotonin causing depression (and drug company advertisements that may inappropriately state this arguable uncertainty):
With direct proof of serotonin deficiency in any mental disorder lacking, the claimed efficacy of SSRIs is often cited as indirect support for the serotonin hypothesis. Yet, this ex juvantibus line of reasoning (i.e., reasoning “backwards” to make assumptions about disease causation based on the response of the disease to a treatment) is logically problematic—the fact that aspirin cures headaches does not prove that headaches are due to low levels of aspirin in the brain. Serotonin researchers from the US National Institute of Mental Health Laboratory of Clinical Science clearly state, “[T]he demonstrated efficacy of selective serotonin reuptake inhibitors…cannot be used as primary evidence for serotonergic dysfunction in the pathophysiology of these disorders”.

Reasoning backwards, from SSRI efficacy to presumed serotonin deficiency, is thus highly contested.
posted by BaxterG4 at 8:34 PM on November 8, 2005


Doesn't LSD act as a seritonin reuptake inhibitor?
posted by Balisong at 9:02 PM on November 8, 2005


I've always been suspicious when complex human phenomenon are boiled down to a single thing. The lipid hypothesis (cholesterol causes heart disease). Cavities and fluoride. Serotonin and depression. There is so much evidence to the contrary.
posted by stbalbach at 9:04 PM on November 8, 2005


Balisong: No, AFAIK.
posted by Gyan at 9:05 PM on November 8, 2005


This is interesting to me on a lot of levels.

I think that even relatively poorly-educated nonspecialist docs recognize that depression is not simply "serotonin deficiency" in the way that pellagra, for example, really is simply "niacin deficency." I was into neuroscience in the early 90's when this stuff was getting hashed out and I can recall at least five more complicated neurologic models of depression, none of which are clearly proven or refuted to date. Some of them at least explain why SSRI's take 6 weeks to kick in, during which time a worsening of the depressive symptoms is to be expected.

So can DTCA have any good effect? Yes; it can destigmatize depression. Recall that Hillary Clinton had a family member who suffered from depression; she was instrumental in many of the health care debates of the 90's (the soi-disant decade of the brain), and IIRC had a special commission to address the destigmatization of mental illness.

However, DTCA is a total load of shit. What a god-awful bunch of messes it causes.
posted by ikkyu2 at 9:33 PM on November 8, 2005


LSD's primary effect is as a direct agonist at certain serotonin receptors, by the way.
posted by ikkyu2 at 9:34 PM on November 8, 2005


I'm not sure anyone has really ever stated with any gravitas that depression was caused by "low serotonin". If the treatment and palliation of illness were predicated on knowing the exact pathology of the disease as well as the specific mechanism by which a given treatment worked then we can forget about treating Multiple Sclerosis, phantom limb pain and reflex sympathetic dystrophy, nearly all back pain, a good deal of the rheumatic diseases, migraines, etc.

Oh, and Dr. Leo is fairly prolific on the web in his critiques of the pharmaceutical industry and the link between mental illness and a neurochemical source.
posted by docpops at 9:36 PM on November 8, 2005


The history of electro-convulsive therapy has always interested me as another example of a treatment for depression that nobody has even the least clue as to how it works.

It was first noted that people with epilepsy, hospitalized for severe depression on psychiatric wards, could experience a brief remission of their depression after a flurry of seizures. Later, when the groundbreaking work of Bernie Lown and others at MGH made it possible for clinicians to interrupt cardiac arrhythmias, cardiologists did some investigation.

They found out that the heart's conduction tissue could become aberrant, producing 'circus rhythms' which would loop around again and again, causing a heartbeat every time the electrical discharge traveled around the circular loop of aberrant tissue. Electrical cardioversion could interrupt this circus rhythm and restore normal cardiac conduction.

Some guy with a wild hair got the idea that an epileptic seizure might be doing the same thing to interrupt a cerebral circus rhythm; except that instead of triggering an aberrant heartbeat, the circus rhythm was triggering a burst of 'depressed mood' every time the discharge went around the cycle. (Anyone who's been depressed will tell you of 'circular thought' patterns that they can't break free of and that make them feel worse every time they go around the circle, which if you were in an unfalsifiable frame of mind, might lead you to give the circus rhythm theory more weight.) So these guys got the idea to "cerebrovert" the brain with electric shocks. Lo; it works.

The circus rhythm that produces depression has never been identified, but people get shocks to their brain every day to treat their refractory depression. And life goes on.
posted by ikkyu2 at 9:41 PM on November 8, 2005


Many of them have humor in them, such as one that went to press (!) with the phrase "[...] what we basically did was collect a shitload of bull semen [...]".

Silly heads. It should have been a "collect a dickload of bull semen [...]".
posted by teece at 9:41 PM on November 8, 2005


No, no, semen comes by the nutload.
posted by nebulawindphone at 10:14 PM on November 8, 2005


MDMA acts as an SSRI, while simultaneously dumping a large percentage of one's serotonin into the synapse, keeping it there for an extended period of time. I have found it to be the best antidepressant out there.
posted by Kifer85 at 11:22 PM on November 8, 2005


Wouldn't bull semen come by the fuckload?
posted by stefanie at 11:57 PM on November 8, 2005


No kidding, Kifer85. I wonder, though, how firmly established that model of MDMA's activity really is. Is that theory based on the serotonin-deficiency model of depression, or is there independent evidence to support it?
posted by Mars Saxman at 12:13 AM on November 9, 2005


Let's get this straight. Anti-depressant drugs are advertised on TV in the USA? WTF? Where is the benefit to consumers - or the medical community - here? Drugs like these should be proscribed by doctors when they recognise that the drugs could help alleviate the symptoms of the patient. Instead, by advertising, you'll have patients demanding to be given these drugs whether they need them or not. Bonkers.
posted by salmacis at 12:56 AM on November 9, 2005


"Where is the benefit to consumers - or the medical community - here? ... you'll have patients demanding to be given these drugs whether they need them or not"

The benefit goes solely to the pharmaceutical companies which is of course why they spend so much money on advertising prescription drugs.
posted by Tenuki at 1:26 AM on November 9, 2005


I found this paragraph especially fascinating:

The FDA has sent ten warning letters to antidepressant manufacturers since 1997 [34–43], but has never cited a pharmaceutical company for the issues covered here. The reasons for their inaction are unclear but seem to result from a deliberate decision at some level of the FDA, rather than an oversight. Since 2002, the first author (JRL) has repeatedly contacted the FDA regarding these issues. The only substantive response was an E-mail received from a regulatory reviewer at the FDA: “Your concern regarding direct-to-consumer advertising raises an interesting issue regarding the validity of reductionistic statements. These statements are used in an attempt to describe the putative mechanisms of neurotransmitter action(s) to the fraction of the public that functions at no higher than a 6th grade reading level” (personal communication, 2002 April 11).
posted by funambulist at 2:07 AM on November 9, 2005


Yes, but the point is - why are the pharmaceutical companies allowed to advertise on television?
posted by salmacis at 2:07 AM on November 9, 2005


Yes, but the point is - why are the pharmaceutical companies allowed to advertise on television?

Because people buy what they are sold, and these ads work. I can't help but think that doctors get mighty tired of people "asking their doctor about" the latest patent nostrum big pharma has cooked up to bolster the bottom line.

I especially like the fact that the costs of lobbying to get favorable legislation to increase profits and limit liabilitiy (as evidenced by the FDA kid-gloves treatment alluded to in the article), as well as the cost of the advertising, is passed on to the consumer, but the reason given for high drug prices is necessary R&D costs.

I guess bribery and false advertising fall under Development.
posted by Enron Hubbard at 2:52 AM on November 9, 2005


No kidding Enron. I remember reading in this Gladwell article that a half a billion dollars were spent to market Nexium. Even in today's business world, that's some read money.
posted by sexymofo at 4:33 AM on November 9, 2005


Why are the pharmaceutical companies allowed to advertise on television?

Why should they not be allowed? The first step in evaluating one's options is knowing what those options are.
posted by Bort at 4:34 AM on November 9, 2005


Bort, I think the article's point is that the ads don't allow you to clearly evaluate the options.

As an Australian I was as surprised as Salmacis to find prescription medicines advertised on TV on a recent trip to the US.

Its bad stuff. Obviously, the argument from the Pharmas is that its educational, and providing 'options', but all I recall are elderly people joyously playing with their grandchildren as the brand name of the drug is plastered across the screen.

I also seem to recall that half the voice-over was consumed by the side-effect warnings.
posted by bramoire at 4:58 AM on November 9, 2005


Good article; unfortunately, similar claims can be made regarding many heavily advertised drugs. For example:

Statins: are advertised based on the unproven link between cholesterol and heart disease in people who are otherwise at low to moderate risk. People who have not had a heart attack and are placed on statins do not live longer; any decreased risk of heart attacks is made up for by an increased risk of death from other causes.

Non-sedating antihistamines: are only non-sedating when given in doses too low to be effective as antihistamines in many people. When given at equipotent doses, these drugs cause drowsiness too.

Cox-2 inhibitors (Celebrex, Vioxx): see your local attorney's billboard or newspaper ad for details.

"Dietary supplements": don't even get me started.

Anti-impotence drugs: hey, I didn't say no drugs work as advertised. Still, these drugs do have side effects that are downplayed and are often used inappropriately, for example to counteract the effect of alcohol, when a much better treatment would be to drink less in the first place.

In fact, that last is an example of why all of this advertising is so bad in the first place. In general, lifestyle changes are much healthier than taking a pill to treat chronic diseases, but there is no money to be made advertising a sensible diet and smoking cessation compared to the profits generated by Mevacor.
posted by TedW at 5:10 AM on November 9, 2005


docpops-I don't think I agree with your first point, in which you seem to suggest that putting into question the over-reliance on SSRIs leaves patients without recourse for treatment. Psychotherapy works as a treatment for depression, and it works as well as medications. Not in every case, of course, but 80% of people in psychotherapy do better than untreated samples. (See the work of statician and psychologist Bruce Wampold.) I think the pertinent question is what treatment works for what patient at what time. The danger with the way SSRIs are presented is that the number of treatment choices narrows to only include meds.
posted by OmieWise at 5:46 AM on November 9, 2005


a half a billion dollars were spent to market Nexium
The snow job they've pulled off must have taken every cent of that. Nexium has almost exactly the same biochemical effect as Prilosec, which is no longer encumbered by patents.
posted by Coventry at 5:54 AM on November 9, 2005


That article was depressing.
posted by nofundy at 5:55 AM on November 9, 2005


Here in Quebec (Canada?) drug ads are even stranger. You apparently can either mention the name of the drug and none of its benefits, or just the (claimed) benefits and not the name. So an add with just the Zoloft packaging and "ask your doctor about Zoloft". Or an ad claiming "depression is a silent killer. SSRI have proven to be very effective in clinical trials. Ask your doctor to tell you more." (Of course the doctor receives lots of samples for Zoloft and nice "conferences" in the Bahamas etc.

But I've seen two ads of either type, for the same product, in the same commercial break so there are ways around this directive.

I'm glad I'm not depressed anymore but officially diagnosed bipolar. (Maybe caused by taking anti-depressants.)
posted by kika at 5:55 AM on November 9, 2005


Okay. I looked this over and then tried to sort it out. As background, I'm no fan of pharmaceutical companies, their advertising, or exaggerations of what antidepressants can do. But, as for this article, I was a bit worried I was swallowing some Scientology propaganda. So I tried to search out the authors to find out if they had this type of "conflict of interest."

Jeffrey LaCasse is working on his PhD in social work. Nice that he is getting some publications out.

Jonathan Leo has a PhD in anatomy and has written a number of articles critical of the biochemical theory of psychiatric diseases. He is listed as a co-editor of Ethical Human Psychology and Psychiatry (EHPP). This is a publication stemming from Peter Breggin's organization, the International Center for the Study of Psychiatry and Psychology (ICSPP). Essentially this group and this journal only focus on critiques of the biochemical theory of psychiatric disease.

From their web-site: "EHPP fills a niche left untouched by other psychiatry and psychology journals. Over the past several years we have published articles about the withdrawal effects of Prozac and Paxil, the ethics of medicating children, deficiencies in the biological theory of mental illness, flaws in the genetic theory of schizophrenia, the marketing tactics of the pharmaceutical companies, common illusions about psychiatric medicine, ethical problems with involuntary treatment, and the benefits of psychotherapy."

Breggin's wife was a member of Scientology, and he is described as a "former ally" (Wikipedia) although now they are critical of it, calling it a cult. Breggin is nothing if not controversial. Some of that controversy is summed up in this Time magazine article:


http://www.holysmoke.org/sdhok/dep03.htm

Also this strangeness regarding Jonathan Leo. He is listed as an associate professor of Anatomy on the Western University of Health Sciences and as Assistant Dean of Student Affairs and Professor of Anatomy at Lake Erie College of Osteopathic Medicine. That would make a very busy schedule.

In summary, from what I've found, this document is not the product of a Scientology crusade. It does come from a group that is fairly absolute in their disbelief in the advantages of psychiatric pharmacology.
posted by dances_with_sneetches at 6:27 AM on November 9, 2005 [1 favorite]


LSD actually acts at lots of receptors: dopamine, serotonin, and adrenergic. I think the jury is still out on just what the hell it does, tho direct agonist activity at serotonin receptors seems to be part of the package.

Fun fact about serotonin: 95% of it is actually in your gut. That's why constipation is a frequent side effect of SSRI's. There are even some fringe people out there who think the antidepressant effects of SSRI's are b/c of activity in the gut, not the brain.

Michae Gershon is an interesting guy who studies what he calls the Second Brain - the surprisingly complicated meshwork of neurons in the gut that guide digestion.
posted by selfmedicating at 6:34 AM on November 9, 2005


Michael. I can't type.
posted by selfmedicating at 6:35 AM on November 9, 2005


MDMA pumps serotonin into the synapse. SSRI's delay the re-uptake of serotonin into the pre-synaptic neuron, a critical distinction.

Statins: are advertised based on the unproven link between cholesterol and heart disease in people who are otherwise at low to moderate risk. People who have not had a heart attack and are placed on statins do not live longer; any decreased risk of heart attacks is made up for by an increased risk of death from other causes.

Emphasis mine.

This is untrue (and somewhat stupid). Recent ultrasonic evaluation of coronary arteries in persons with "clean" heart caths clearly show plaque development in the walls of the artery, directly proportional to LDL levels. Statin drugs are probably as revolutionary as they make themselves out to be. What utility they have in a person at low risk of heart disease is not shown as yet.

Omiewise: I agree completely with the tenor of your point on psychotherapy. But for the great majority of people it is impossible to fulfill such an endeavor. All medical care is predicated on real world limitation. Most psychological distress stems from poor cognitive reactions to stressors or the results of chronic poor choices. Physicians in the trenches are asked to help assuage debilitating mental illness and simply don't have the luxury of impractical or impossible but possibly more logical solutions.
posted by docpops at 7:12 AM on November 9, 2005


This is untrue (and somewhat stupid).

The truth of that statement may be debateable; medical science marches on. In support of my contention:

The analysis of the five trials was conducted by a team of researchers at the University of British Columbia led by James M. Wright, PhD, who came to the alarming conclusion that statins harm as many people as they help. True, the combined results of the five trials did, in fact, show a lower rate of non-fatal heart attack and stroke. However, once serious adverse events* were taken into account, the results were not so positive. The statin users did have 1.4% lower rate of heart attack within the next five years, compared with untreated people, but that small benefit was offset by a 1.8% rate of serious adverse events associated with the drug.

Dr. Wright and colleagues might be the first reviewers to step back and look at the big picture--assessing the serious risks as well as the benefits of statins. Only two of the five trials reported serious adverse events. “Based on the two trials, we are suspicious that some serious adverse events are being increased by statins and that this appears to be canceling the benefit of the reduction in heart attacks and strokes,” Dr. Wright wrote in an e-mail interview. The new analysis was published in the April-June 2003 issue of Therapeutics Initiative, an evidence-based drug therapy newsletter (“Do Statins Have a Role in Primary Prevention?” Available free at www.ti.ubc.ca).


The rest of the article is here. Apparently there are other stupid people out there who believe that statins are unproven drugs whose risks may well outweigh their benefits if they are given to large segments of the population, and more pertinant to the thread, drugs that are advertised as being far more useful than they are.
posted by TedW at 7:37 AM on November 9, 2005


TedW - I'm still a bit suspicious, mainly b/c the home page of the site you link also has an article about the "unproven" value of flu vaccines for young children. Conventionial medical wisdom IS wrong sometimes, but most of the time it isn't.

Having said that I don't think your statins argument is "stupid" (and it bugs me to see that kind of namecalling on mefi). It's given me something to think about.
posted by selfmedicating at 7:52 AM on November 9, 2005


Yet, this ex juvantibus line of reasoning (i.e., reasoning “backwards” to make assumptions about disease causation based on the response of the disease to a treatment) is logically problematic—the fact that aspirin cures headaches does not prove that headaches are due to low levels of aspirin in the brain.

This is an example of using flawed logic to argue that the logic is flawed. Aspirin doesn't exist in the brain before the administration of aspirin, therefore we don't hypothesize that aspirin cures aspirin deficiency.
posted by eperker at 8:50 AM on November 9, 2005


eperker writes "This is an example of using flawed logic to argue that the logic is flawed. Aspirin doesn't exist in the brain before the administration of aspirin, therefore we don't hypothesize that aspirin cures aspirin deficiency."

This is a good point. It doesn't invalidate the rest of the article, but it's a very good point.
posted by OmieWise at 9:01 AM on November 9, 2005


There are numerous double blinded studies that clearly show substantial reductions in heart attack and stroke in both primary and secondary settings.

ALLHAT, if you look at it's design, included as"usual care" the use of cholesterol medication in it's control group. It also was not double-blinded. There are strong reasons why they concluded a lack of significant reduction in cardiovascular mortality in the pravastatin-treated cohort. Specifically, the study extended only six years, which in a clinical timeframe is a blink of an eye, and as mentioned above, by the time of the studies conclusion, only 70 percent of the treated group was actually still using the drug, and almost thirty percent of the control group was still on drug therapy as well.

What I really love are the numerous websites that quote ALLHAT right before they try to sell you their own snake oil for cholesterol reduction. The latest and greatest is red yeast rice extract. All the risks of hepatotoxicity and myositis with none of the quality control.

And I apologize for the "stupid" comment.
posted by docpops at 9:07 AM on November 9, 2005


selfmedicating: thanks for looking at my info with a critical eye and open mind. I agree that the site I linked to can be a bit anti-establishment at times, but I have been in medicine for 16 years and know that conventional wisdom can be wrong far more often than we like to think. Look no further than this year's Nobel Prize in Medicine to see just how wrong conventional wisdom can be. If you want another source for information on statins, look here for a critique of the five largest studies (as of 2003) of statins in people who have not had heart attacks.
posted by TedW at 9:10 AM on November 9, 2005


eperker : "This is an example of using flawed logic to argue that the logic is flawed. Aspirin doesn't exist in the brain before the administration of aspirin, therefore we don't hypothesize that aspirin cures aspirin deficiency."

The basic point is that treatment is not necessarily a mirror image of the cause of the ailment. The aspirin example was brought up because aspirin doesn't exist in the brain. If it did, then we might not be sure that aspirin deficiency wasn't the problem.
posted by Gyan at 9:30 AM on November 9, 2005


Docpops, apology accepted, but really not needed; it will be a high water mark for civility on Metafilter when calling something stupid is the worst thing that is said all day.

As regards the ALLHAT study, it confirms that statins are useful in high-risk patients, but in patients with low to moderate risk for heart disease, there was only a small, statistically insignificant drop in the risk of heart attack, and no decrease in mortality (which is, after all, a major goal of the therapy). Other studies, such as PROSPER, have shown a small (and also statistically insignificant) increase in cancer in those patients treated with statins. And lets not forget Baychol, the statin that was withdrawn from the market after being implicated in the deaths of 31 patients taking the drug.

Even when they work statins generally only lower cholesterol by modest amounts in most patients; total cholesterol by 10% and LDL cholesterol by 17% in ALLHAT; will going from a total cholesterol of 240 to 216 really make that big a difference in most people, especially if they have to take a drug every day for the rest of their life to achieve it? And all of this talk about cholesterol begs the question aof whether lowering cholesterol is the most effective way to prevent heart attacks. In addition to lipids, inflammation, platelet function, and coronary vascular tone all contribute to myocardial infarction, and any approach that targets only one factor will be of limited efficacy.

Finally, to try and undo this derail (I think the original post said something about depression), this debate shows that there is a good deal of difference of opinion among medical professionals on something as well-studied and understood as heart disease. In spite of that the drug companies advertise these drugs as if their benefits for everyone are commonly accepted. Psychiatric diseases and treatments are further ouside of my are of knowledge, but I know they are less well understood in terms of their underlying biology. Once again, the drug companies advertise their products as if their mode of action and effectiveness for large, diverse groups of patients are a foregone conclusion. I can certainly agree with docpops and ikkyu2 that drug advertising is shit. I think I'll get back to work now; this post kind of grew out of control.
posted by TedW at 9:46 AM on November 9, 2005


Gyan writes "The aspirin example was brought up because aspirin doesn't exist in the brain. If it did, then we might not be sure that aspirin deficiency wasn't the problem."

Also a good point.
posted by OmieWise at 9:55 AM on November 9, 2005


TedW,

Thanks for all that. In practice, I utilize Lipitor/atorvastatin pretty much exclusively in high risk patients, typically diabetics, proven vasculopaths, obese w/multiple comorbidities, etc. If the reductions in LDL were paltry, then yes, I would agree that it isn't worth the cost and risk.

However, given the data I have seen on LDL's inflammatory injury to vessels, and the fact that I frequently see 30-50 percent LDL reductions on doses of 5-10 mg (out of 80 max), I am in favor of aggressive lipid lowering.

It's very, very difficult to reconcile study data with what we see in practice at times. The ALLHAT arm that supports diuretic usage as first line therapy is similarly ludicrous. When is the last time you tried giving twenty hypertensives more than 25 mg. of HCTZ without a half dozen calls for nausea and dysequilibrium? I feel like sometimes these researchers have never set foot in an office or treated an actual, random, typical patient (not one actively caught up in the environment of a research study).
posted by docpops at 10:00 AM on November 9, 2005


Physicians in the trenches are asked to help assuage debilitating mental illness and simply don't have the luxury of impractical or impossible but possibly more logical solutions.

What? This statement worries me greatly. I don't understand how psychotherapy is being labeled as "impractical or impossible" while using drugs that operate on an unproven premise is acceptable. I have long been suspicious of the use of advertisements to push SSRIs on consumers and even more alarmed at the number of people who use these drugs but do not pursue any sort of psychotherapy. It seems like in a properly run medical system there would be a way to prescribe the more logical solutions to a problem.

And secondly, shouldn't a doctor faced with a situation they cannot address refer that person to a specialist before prescribing the weekly flavor of SSRIs, or are people to busy going to luncheons and scribbling with their free pens?
posted by elwoodwiles at 10:10 AM on November 9, 2005


The first time I had to teach the statins to medical students, I went to the original literature to look at their efficacy. I was shocked by these so-called wonder drugs. The AFCAPS study, at that time the study that did the most to look at their effect in patients with moderate cholesterol and no prior heart attacks, had these drugs reducing deaths by coronary disease by a statistically significant degree. However, the overall death rate (cardiac and non) increased. They pointed out that this was not significant, but if you can divide up the deaths into cardiac and non, get a statistically significant result to the good for cardiac, why wouldn't you get a statistically significant result for non? Why? Because when measuring the overall death rate, they lumped everything together. When examining the good news, they pulled them apart. And when they stopped the study early because of the good news.

Statins are good for genetic cholesterol disorders, diabetics, and probably post-heart attack. For others, I would avoid them. There is a whole history of pharmaceutics that treat symptoms and kill the patient.
posted by dances_with_sneetches at 10:52 AM on November 9, 2005


Elwoodwiles:

Here's a wish list:

Physical therapy for the injured and chronically in pain.
Counseling for the depressed.
Inexpensive sources of antibiotics and antihypertensives for the sick.

As Billy Bob Thornton says, "Shit in one hand and wish with the other and see which fills up faster."

I'm not sure if you are being willfully obtuse with your comments. What don't you understand about the impracticality of prescribing 150$/hour, weekly sessions of psychotherapy to any average american? Don't construe acquiescence with agreement on my part. But try a bit harder to see reality.
posted by docpops at 10:58 AM on November 9, 2005


or are people to busy going to luncheons and scribbling with their free pens?

Almost missed that. I was tempted to tell you to go fuck yourself, but instead will just tell you you're an idiot if there's any real sentiment behind that comment.
posted by docpops at 11:02 AM on November 9, 2005


Hey, we have the same wish list! Though I'm not sure, exactly, what your Thornton quote is trying to express.

I'm sorry if you are caught in a tough situation where the very medical industry you work for makes it difficult to adequately treat patients. What I understand is that there are proven methods that do work, but do not involve using poorly understood manipulations of brain chemicals. The use of SSRIs in the general population is pervasive (as your posts imply) not because they are a better treatment, but because they are cheaper, easier and in the end more profitable to the medical industry. That's a reality that is not at all hard to see.

Not only can I not find it in myself to agree to such a situation, I don't seem willing to acquiesce either.
posted by elwoodwiles at 11:11 AM on November 9, 2005


150$/hour, weekly sessions of psychotherapy

Holy cow, is that an average rate in the US?
posted by funambulist at 11:28 AM on November 9, 2005


Not only can I not find it in myself to agree to such a situation, I don't seem willing to acquiesce either.

Good for you. And I'm sure no one will have a problem with you avoiding SSRI or any other psychopharmacologic treatment. And possibly any beneficial treatment that isn't proven. That's the beauty of having options and choices.

As well, I work for the "medical industry" as much as you live and breathe in the "government industry". Medical options and resources are a direct result of societal issues, not the born-in-a-vacuum decisions of middle managers at insurance companies. I'm not sorry at all for the lack of adequate counseling resources. Any more than I bemoan the lack of options for battered women, the insane, fat kids, pregnant uninsured women, or any other marginalized component of society. It's not the fault of medicine and never will be. I'm just thankful as all hell that when they show up at my office, to get into the gritty reality that you likely haven't a clue about, that I have some other option besides a calming hand on their shoulder.
posted by docpops at 11:32 AM on November 9, 2005


I was tempted to tell you to go fuck yourself, but instead will just tell you you're an idiot if there's any real sentiment behind that comment.

Is that an official diagnosis? Perhaps you could give me something to help out.

Or maybe you could either answer the question or show it to be a false dilemma of some kind. As it stands, Big Pharma markets aggressively to both the public and to practitioners.

On preview: Before insurance kicks in, yes. Yet at the same time very few therapists see $150 an hour. Really, though, if someone has insurance they should be able to work out something that gives them access to therapy. Insurance companies make this difficult, but not "impractical or impossible."
posted by elwoodwiles at 11:34 AM on November 9, 2005


EW,

I already made it clear that I'm no fan of the pharmaceutical industries marketing practices, which is separate from the issue of pharmacologic efficacy of SSRI's.

And in most markets, less than half the population has medical insurance. Many who do do not have coverage for mental health. If they do, it is limited to "x visits per 12 month cycle" or some other bullshit.
posted by docpops at 11:40 AM on November 9, 2005


I already made it clear that I'm no fan of the pharmaceutical industries marketing practices, which is separate from the issue of pharmacologic efficacy of SSRI's.

Really it's not. The perceived efficacy of SSRI's is partially a result of their marketing practices.

in most markets, less than half the population has medical insurance. Many who do do not have coverage for mental health. If they do, it is limited to "x visits per 12 month cycle" or some other bullshit.

We agree that the lack of access to medical care is a problem, but how is prescribing SSRI's the solution? You speak of logical solutions being a luxury, of therapy being little better for "the insane, fat kids" than a "calming hand on the shoulder," of gritty realities I don't understand - all to be cured with a few pills.

In some cases acquiescence is agreement.
posted by elwoodwiles at 12:02 PM on November 9, 2005


funambulist writes "150$/hour, weekly sessions of psychotherapy

"Holy cow, is that an average rate in the US?"


Not even close, unless you're a psychiatrist prescribing meds, then the rate is higher, maybe $150/15 minutes.
posted by OmieWise at 12:05 PM on November 9, 2005


Point taken.

I'm sending in my resignation.
posted by docpops at 12:23 PM on November 9, 2005


I was seeing a psych doc for what could probably be called mild depression. He put me on Zoloft. One day leaving the office I was writing my check for the copay at the front desk and the doc was within earshot of me talking with a "rep" from the drug company. The "rep" was basically telling the doc to prescribe zoloft first for all of his patients and the doc was agreeing with him. It was disgusting and I never went back.

I have tried other drugs of this type in the past and they are hell to try and get off of. I would not reccomend them unless you are severly depressed.
posted by Justin Case at 1:20 PM on November 9, 2005


The use of SSRIs in the general population is pervasive (as your posts imply) not because they are a better treatment, but because they are cheaper, easier and in the end more profitable to the medical industry.

Possibly, but you overlook a major difference between SSRIs and the tricyclics that were the drug of choice for depression before the Prozac era: it's easy to overdose on tricyclics; it's all but impossible with SSRIs. This key difference is what made SSRIs seem like something the family doctor could prescribe, without watching his patients like a hawk.

Or so I was given to understand, back in my Prozac days.
posted by dhartung at 8:13 PM on November 9, 2005


docpops: I share your skepticism, bafflement and bewilderment when trying to "translate" soi-disant "translational" clinical research trials into clinical practice, and never mind the epidemiological hard data.

For instance, in the case of stroke, ramipril, an ACE inhibitor clearly reduces risk of stroke recurrence (SAVE trial), while having no measurable effect on measured blood pressure. I have seen unpublished data from the NOMASS (Northern Manhattan Acute Stroke Study) that proves that -statins reduce stroke risk and stroke recurrence even though they do not lower cholesterol levels.

What are we to do with this data?

Also, comparing a 1.4% risk of heart attack with a 1.7% risk of "serious adverse event" in statin therapy is foolish. "serious adverse event" means "serious enough to discontinue therapy;" in the case of statin therapy, that can mean things like: asymptomatic elevation of serum CK; myalgias; asymptomatic elevation of serum transaminases. It is not reasonable to compare a "serious event" such as asymptomatic change in a blood test to heart attack, which is the number one killer of human beings nationwide. Heart attack is far more serious.
posted by ikkyu2 at 4:20 PM on November 10, 2005


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