Transcript Drugs Might Be the Problem!

Drugs Might Be The Problem!
Does Our Thinking About Mental Health Increase the
Risk of Suicide?
Angela Bischoff
David Zitner
Depression: Important ProblemImaginary Illness
• The adjective mental in mental illness refers to
the doctor’s mind not the patient’s. When we use
the term “mental illness” we are speculating that
the person suffers from a physiological
derangement causing abnormal thoughts,
feelings and behavior.
• When the physiologic cause is known we do not
classify the problem as a “mental illness”
Depression is Not an Illness Using
Any Conventional Definition
• OED DEFINITION OF ILLNESS: bad or
unhealthy condition of the body (or, formerly,
of some part of it)
• There is no evidence that people diagnosed with
depression have a “bad or unhealthy condition
of the body”. Depressed people with thyroid,
Addisons or other depressing conditions are not
told they have a depression (they know they feel
bad!) or biochemical imbalance. When people
have a real illness we tell them what it is.
– When it is mere speculation we call it a
biochemical imbalance
How We Think About Depression
Depression is a serious problem
a) Depressed people are uncomfortable
b) Depressed people are dysfunctional -- they
accomplish less
c) Depressed people are more likely to die.
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Cf. Blumenthal et al. for Cardiac Bypass
Cf. Loberizo et al. for Stem Cell patients
8,513,000 visits for depression in 2002
Psychotherapeutic drugs second most widely
prescribed class after anti-hypertensives
Changes in Thinking About
Depression
• Paxil banned in Britain for those under 18.
• Alan Metz, Vice-President for Clinical Development at
Glaxo, said in court papers:
– "It's not possible really to measure total serotonin." He
added that "we do not know with absolute certainty about
how any of the antidepressants work."
• “If the drug companies can't really measure what
normal serotonin levels are, and they don't know
really how the drugs work, then how can we say they
restore balance? “
As reported by Greg Critser, January 25/04, L.A. Times
Canadian Depression Study 2003
• The top symptoms are similar to those experienced
by people who are de-conditioned: those who eat
poorly and don’t exercise
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Fatigue
Loss of Interest
Depressed Mood
Tense/Nervous/Irritable
Impaired Concentration
96%
96%
95%
95%
93%
• ABNORMAL PHYSIOLOGY/BIOCHEMISTRY IS
NOT A NECESSARY CONDITION FOR FEELING
BAD
SSRIs: Estimated Number of Pills (000s)
Dispensed from Retail Pharmacies
700,000
600,000
5 Year Growth:
Nova Scotia --- 65.8%
Canada --- 77.5%
# Pills (000s)
500,000
400,000
300,000
200,000
100,000
0
Nova Scotia
Canada
1999
2000
2001
2002
2003
MAT Sep 04
13,895
16,642
18,802
20,730
23,784
23,039
388,130
458,019
521,466
584,177
653,065
688,789
Source: IMS Health - Compuscript
SSRIs: Physician Prescribing in Nova Scotia
Physician Quartiles by Rx Volume – Year 2003
(Total Rxs = 422,392)
A small number of docs prescribe most of these drugs
Average Rx per Physician
1,200
1400
1,000
1200
Avg. Rx per Physician
1000
# of Physicians
800
800
600
600
400
400
200
200
0
0
1484
854
547
96
# of Physicians
71
124
193
1,099
% of Total Physicians
4.8
8.3
13.0
73.9
Avg. Rx per Physician
Source: IMS Health - XPONENT
# of Physicians per Quartile
1600
Wellbutrin Promotional Material
• “The effectiveness of Buproprion in long
term use-more than 8 weeks has not been
systematically evaluated”
• Dosing: “The full antidepressant effect
may not be evident until several weeks of
treatment”
• A single dose “…produced amphetamine
like effects compared to placebo..”
• Seizures = 1/1,000 patients
Drug Industry Document:
Lilly -- March 29, 1985
• “The incidence rate (suicide) under fluoxetine (Prozac)
therefore purely mathematically is 5.6 times higher than
under the other active medication imipramine." . . . "The
benefits vs. risks considerations for fluoxetine (Prozac)
currently does not fall clearly in favor of the benefits.
(March 29, 1985). Therefore, it is of the greatest
importance that it be determined whether there is a
particular subgroup of patients who respond better to
fluoxetine (Prozac) than to imipramine, so that the
higher incidence of suicide attempts may be
tolerable."
Cited by Baum and Hedland Feb, 2, 2004
http://www.baumhedlundlaw.com/media/timeline.html
Are Drugs Necessary?
Available studies of apparently comparable
subjects show similar rates of clinical
response to either psychotherapy or
medication. Therefore, either approach
can be empirically justified, with a choice
between medication and psychotherapy
based on clinicians' and patients'
preference.
(Brent, D.A., and Birmaher, B., Adolescent depression. NEJM 347:
667-671 (August 29), 2002)
Little Evidence That SSRI’s Are
Effective
• The degree of multiple publication, selective
publication, and selective reporting differed
between products. Thus, any attempt to
recommend a specific selective serotonin
reuptake inhibitor from the publicly available
data only is likely to be based on biased
evidence.
(Melander H, et al. Evidence b(i)ased medicine—selective reporting
from studies sponsored by pharmaceutical industry: review of
studies in new drug applications. BMJ 2003 (May 31); 326: 11711173.
Side Effects: General
25%+ of users have side effects
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Dry mouth
Sexual dysfunction
Constipation
Urinary retention
Nausea
Greater withdrawal
from drug than
placebo patients
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Sleep disturbance
Tremor
Weight gain
Sweating
Dizziness
(orthostatic
hypotension)
Little Evidence That SSRIs Are
Effective
• When Kirch et al. reviewed material sent
to the American FDA, they found poor
evidence of significant benefit compared to
placebo either statistically or clinically.
Kirch I, et al. The Emperor's New Drugs: An Analysis of
Antidepressant Medication Data Submitted to the U.S.
Food and Drug Administration. Prevention & Treatment,
5, Article 23, posted July 15, 2002.
http://journals.apa.org/prevention/volume5/pre0050023a.html
Little Evidence That SSRIs Are
Effective
• Moncrieff’s observations might suggest that
depression is susceptible to a variety of nondisease-specific pharmacological actions such
as sedation or psycho-stimulation, as well as the
effects of suggestion. These effects may account
for at least part of the impact of conventionally
classified antidepressants.
Moncrieff J: Are Antidepresssants Overrated? A Review of
Methodological Problems in Antidepressant Trials. Journal of Nervous &
Mental Diseases 189(5): 288-295, 2001 (May)
Results
• No Studies Proving that Antidepressants
Actually Reduce Suicide!
• Harvard
http://www.baumhedlundlaw.com/media/ssri/paxil/h
arvard%20doc.PDF
• Studies suggest it is more likely these
drugs are associated with increased
suicide rates
Harms of SSRIs
• SSRIs Cause or Exacerbate
– Obsessive preoccupations, agitation, agitated
depression manic psychoses
– Suicidality, Violence and Extreme Abnormal Behavior
– Evidence is from clinical reports, controlled clinical
trials, and epidemiological studies in children and
adults.
(Breggin, P.J. Suicidality, violence and mania caused by selective serotonin reuptake
inhibitors: A review and analysis. International Journal of Risk & Safety in Medicine 16
(2003/2004) 31–49 31)
• There are medico-legal implications as well:
Physicians need to inform patients about
side effects and lack of effectiveness; At
least inform them about the controversy
regardless of personal beliefs! (Ginn)
We Harm Depressed People
• Long term antidepressant use may worsen
depression
(Fava G et al. Can long term treatment with antidepressant
drugs worsen the course of depression? Journal of
Clinical Psychiatry, 2003, Feb;64(2):123-33)
• A number of reported clinical findings point to the
very unfavorable long-term outcomes of major
depression treated by pharmacologic means,
• Paradoxical (depression-inducing) effects of
antidepressant drugs in some patients
Purpose of Psychiatric
Interventions
• To change thoughts, feelings and behavior.
• Methods to modify mood
– Lifestyle
– Psychotherapy (talking therapies)
– Drugs
– Surgery and other physical methods –
Lobotomy, Electroconvulsive Therapy
– CCT-Cranial Clunk Therapy???
Ways of Treating Depression
• Lifestyle
– Diet and Exercise
• Talking or psychotherapies
– Acceptance of context
– Motivating discussion
• Substances
– Drugs, but which ones and when?
– As the CEO of Glaxo Wellcome remarked we don’t
really know what is the biochemical imbalance.
More Articles
Szasz, T. The psychiatric protection order for
the ‘battered mental patient’. BMJ, Dec
2003; 327: 1449 - 1451.